The death of a schoolboy with a dairy allergy who had cheese thrown at him by a fellow pupil was the consequence of a “childish and thoughtless act”, but one that was not calculated to cause him harm, a coroner has said.
Karanbir Singh Cheema, 13, known as Karan, went from being “absolutely fine” to unconscious in less than 10 minutes after the incident at William Perkin Church of England high school in Greenford, west London, on 28 June 2017. Karan, who had multiple food allergies as well as asthma and chronic eczema, died 10 days later at Great Ormond Street hospital with his family at his side.
Returning a narrative verdict at St Pancras coroner’s court on Friday, the senior coroner for inner north London, Mary Hassell, said the boy who threw the cheese and the one who passed it to him had no intention to harm Karan.
It was a “childish and thoughtless act but was not calculated to cause serious harm”, she said.
However, Hassell said the school had failed to educate pupils about the “grave consequences” of Karan’s allergies, and that the school’s healthcare provision was inadequate.
She said: “Karanbir’s school did not have an effective system for educating its pupils in the dangers of allergies.”
The coroner said she would be issuing reports on the prevention of future death to nine different organisations, including the school, the Department for Education and the Department of Health, in an attempt to guard against similar incidents.
“Karanbir died because he had an allergic reaction to cheese that was thrown at him by a fellow pupil … His fatal reaction to an allergen that was not ingested but was only ever in contact with his skin was extraordinarily rare,” Hassell said.
During three days of evidence last week, the court heard that although Karan was a “pretty typical patient” at allergy clinics, his death from anaphylactic shock brought about by skin contact was unprecedented.
Dr Adam Fox, a consultant paediatrician and leading expert on anaphylaxis, who was brought in by the Metropolitan police to review the case, said: “If it was skin contact alone that caused, in this case, fatal anaphylaxis, I believe that would be unprecedented … I have never seen it before. I have been unable to see any cases reported of a fatal anaphylaxis [through skin contact].”
The boy who flicked the cheese and another boy who passed it to him gave evidence from behind a screen during the hearing. Both aged 13 at the time of the incident, the boys told the inquest they were unaware Karan had an allergy.
Dame Alice Hudson, the executive headteacher of the Twyford Trust, encompassing the school, told the inquest she believed the pair did know about Karan’s allergy. However, under questioning, she accepted her view was speculative.