Nasar Ahmed

r~t:bj 

Barts Health 
NHS Trust 

Trust Executive Offices 
Barts Health NHS Trust 
Pathology and Pharmacy Building 
80 Newark Street 
London 
E1  2ES 

Dr. Hassell 
Senior Coroner 
Inner North London 
St Pancras Coroner's Court 
Carnley Street 
London 
N1C 4PP 

14 July 2017 

Dear Dr. Hassell, 

I  am  writing  in  response  to  the  Regulation  28  (Prevention  of Future  Deaths)  report 
into the death of Nasar Ahmed. 

First  and  foremost  our  thoughts  are  with  Nasar's  family  in  what  must  be  a  very 
difficult  time  for  them.  We  also  recognise  that  Nasar's  death  has  had  a  significant 
impact  on  health  and  education  professionals  across  Tower  Hamlets  and  that  the 
teams treating Nasar at the Royal London Hospital have been deeply affected by it. 

We  have  considered  the  circumstances  around  Nasar Ahmed's  death  and  each  of 
the concerns you raise.  We have addressed these concerns in  the form  of an  action 
plan attached. In addition  to  actions addressing the  concerns specified in your report 
we will work with partners to fulfil the following system wide actions: 

Implementation of the Asthma Friendly Schools Project 

Universal use of the Healthy London Partnership Paediatric asthma toolkit for training 
staff across health and education. 

Enhanced  knowledge  of  long  term  conditions  in  childhood  to  improve  health, 
education and individuals self-management of chronic health prqblems. 

 
 
 
 
 r~t:bj

Barts  Health 
NHS Trust 

Standardisation of acute and chronic asthma management across Tower Hamlets in 
line with the London Paediatric Asthma standards and  incorporating the NICE quality 
standard  and  the  proposed  diagnosis  and  management  standard  to  be  published 
October  2017. This work  will  be  supported  by the  North  East  London  Children  and 
Young People's Asthma Alliance. 

I trust that our response  addresses your concerns and  that the  action plan  supports 
the  prevention  of future  deaths  from  acute  asthma  and  anaphylaxis.  If there  is  any 
further information you require please do not hesitate to contact me. 

Yours sincerely, 

Deputy Chief Medical Officer 
Barts Health NHS Trust 

Attachment: Barts Health NHS Trust Regulation 28 action plan

BOW 
SCHOOL 

29th June 2017 

1 

Bow School's Response to Prevention of Future Deaths Report 

On  the  12.05.17,  following  the  Inquest into  the  untimely  death  of Nasar Ahmed , the  Senior 
Coroner for the  Inner North  London  Coroner Court made  a  request  under the  Coroner and 
Justice  Act  2009  and  reg.28  Coroners  (Investigations)  Regulations  2013  for  a  report  from 
Bow  School  setting  out  what  actions  have  been  taken  to  prevent  future  deaths  arising  if 
similar  circumstances  were  to  occur  again.  Alongside  this  request  the  Coroner  made  four 
further requests from a number of agencies under reg .28. 

This report addresses the  matters of concern  raised  directly  to  the  school.  Please note that, 
in  addition  to  the  actions  detailed  within  this  report,  the  school  has  actively  engaged  with 
other organisations,  including  Compass Wellbeing and Barts  NHS  Trust,  to  support them  to 
review  practices  and  implement actions  within  their  organisations  to  protect  against future 
deaths in  school settings.  School  staff are  also  working  with  the  Local Authority's  Education 
Department  and  Tower  Hamlet's  Education  ['THE']  Partnership  to  raise  awareness  with 
schools across  the  area  of the  steps they  have  taken to  minimise risk of similar incidences. 
The  school  remain  committed  to  working  with  parents  and  pupils  to  manage  medical 
conditions  effectively .  They  recognise  that  key  to  this  is  improving  existing  systems  and 
ensuring  these  are  robustly  monitored  to  accurately  identify  needs  and  reduce  risk.  Also 
pivotal  to  the  improvements  is  a  commitment  to  supporting  staff  to  provide  effective 
preventative interventions and prompt response to  medical emergencies. 

The  Coroner  commented  within  the  report  that  Nasar's  mother  was  present  for  the 
medication review conducted by the  school nurse on the 03.05.16, but that a member of staff 
wasn't present.  She commented that this was contrary to the school policy. It should be noted 
that,  at  time  of Nasar's  death,  the  'Supporting  Student  with  medical  needs'  policy  did  not 
require  a  member  of staff  to  attend  the  annual  review  of an  Individual  Health  Care  Plan; 
rather the requirement was that staff were  involved  in  the original decision  to  have a plan. 1  It 
should  also  be  noted  that  this  policy  complied  with  the  standards  expected  by  national 
guidance for schools  including  'Supporting pupils at school with  medical conditions  statutory 
guidance  for  governing  bodies'2
,  the  'Special  Educational  Needs  and  Disability  Code  of 
Practice3  and 'Keeping children safe in  Education4

. 

Notwithstanding  this  the  school  has  revised  the  relevant policy to  require  that a  member of 
pastoral  team  responsible  for  the  child,  (usually  the  Year  Learning  Manager  ['YLM'J or the 
Year  Learning  Assistant  (YLA])  attends  the  initial  meeting  and  all  reviews.  It has also  been 
amended  so  it  no  longer  requires  a  first  aider  to  contact  the  Head  teacher's  personal 
assistant  to  call  emergency  services, but rather  requires  staff do this  immediately  and  then 

See page 4 of 2016 policy 

1 
2  Published by the Department for Education. available at: 
https://www.gov.uk/governmenVpublications/supporting-pupils-at-school-with-medical-conditions-3 
3 

4 

https://www.gov.uk/governmenVpublications/send-code-of-practice-O-to-25 
https://www.gov.uk/governm enVpublications/keeping-children-safe-in-education--2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2 

notify  the  office  so  that  parents  can  be  informed  at  the  earliest  opportunity.  The  revised 
policies are due to be ratified  at the next Governing  Body  meeting on  the 12.07 .17,  but staff 
have already implemented these changes into their practice. 

The  Coroner also  raised  concerns that the  system  in  place for ensuring  that actions  arising 
from  individual  health  plans  ('IHP']  and  medication  reviews  were  undertaken  was  not 
sufficiently  robust.  Since  Nasar's  death, 
the  school's  Safeguarding  Committee  has 
undertaken a thorough review of all  IHPs for pupils in the school. This included ensuring that 
all medicines kept within emergency boxes at the school are as prescribed and in date. 

The  Executive  Headteacher,  along  with  Headteacher representatives  from  across the  area, 
has been  invited by the Local authority to meet to discuss the school  nursing service  as part 
of a scheduled contract renewal process. This meeting is due to take place later this year, but 
it is understood that the  concerns identified during the  Inquest will inform that process.  In the 
interim  the  school  has  been  working  with  Compass  Wellbeing  to  clarify  the  procedure  for 
setting  up  IHP  meetings  and  medication  reviews.  The  school  has  additional  processes  to 
ensure this procedure is robustly monitored at senior level. The procedure requires that,  in  all 
cases an update of the pupil's medical need is required at each review.  Principally it remains 
the responsibility of the child's parents or school nurse to make contact with the child's GP or 
other medical  professionals involved  in their care  prior to  the meeting. Where,  at the  review 
meeting,  this hasn't been  done or there is any uncertainty regarding the pupil's current need 
the school nurse is  required  to follow up with direct contact to the pupil's GP and  confirm the 
position  to  the school administrator by email.  The deputy  head  responsible  for safeguarding 
is  also  copied  into  those  emails.  The  procedure  also  differentiates  between  medication 
reviews  and  IHP  meetings/  reviews  to  ensure  that  necessary  follow  up  can  be  scheduled 
separately.  For example,  where  actions are  required  as  a  result of the  medication  review,  a 
follow up review is scheduled for the following week.  Currently both the school nurse and the 
attending  member of staff are  required to  notify the school administrator if follow  up action  is 
required  following  a  review.  A  reminder  is  sent  by  the  administrator  shortly  before  the 
deadline for action to the school nursing service and VLM. 

The  Safeguarding Committee5 has developed a flowchart to outline the  responsibilities under 
the  'Support students with  medical  needs'  policy.  The  committee  has  as  a standard  agenda 
item  'IHP  and  medication  reviews'  so  that  effectiveness  of  managing  medical  needs  is 
considered  at each  meeting.  It is responsible for setting the schedule of meetings for all  IHP 
or medication  reviews  on  a  half termly  basis.  The  school  administrator is  required  to  liaise 
with  Compass  Wellbeing  and  the  YLM  to  ensure  all  parties  are  present  at  meetings.  The 
Designated  Safeguarding  Lead  ['DSL']  also  receives  details  of  IHP  .meetings  and  the 
decisions  made  and  conducts  spot checks  on  the  IHPs  and  medicines so  that  compliance 
with  expectations can  be  maintained. The  DSL  provides a compliance  report each half term 
to the safeguarding committee.  In addition,  senior leaders at the school meet with Compass 
Wellbeing  managers  on  a  termly  basis to  review  practice,  the  implementation  of the  policy 
and  procedures  and  to  assess  the  quality  of communications  between  the  school  nursing 
service  and  pastoral teams within the school. Any concerns regarding  compliance with  those 
expectations or training needs of staff are also addressed at that meeting. 

6 This committee is Chaired by the Deputy Head with safeguarding responsibllltles and attended by the 
Designated safeguarding lead, the Governor responsible for safeguarding,  the SENOCo, Child protection 
officer, senior first aider, senior colleague responsible for trips and visits, the heads of the upper and lower 
school and the HR manager who maintains the School's Single Central Register. 

 3 

The  Coroner commented  that  school  staff were  encouraged  to  familiarise  themselves  with 
pupil's  care  plans  and  required  to  do  so  for  school  excursions,  but  in  other circumstances 
staff may not have been familiar with  health needs of all pupils.  In response to this the school 
now  have  a  clear  understanding  between  Compass  Wellbeing,  parents  and  pupils  that 
information regarding a child's medical needs will  be shared with  all staff on  the basis that all 
staff need  to  have  access  to,  and  understanding  of,  this  information.  This  information  has 
been  made  more  visible  for  staff as  detailed  below  and  policies  and  processes  have  been 
revised  to  reflect  this  common  understanding,  for  example,  all  staff  have  access  to  the 
school's  electronic  medical  needs  registers.  The  amended  polices  are due  to  be  ratified  by 
the Governing Body on the 12.07.17. 

In  addition,  the  induction  programme  for  new  staff  has  been  amended  to  include  medical 
needs  information  in  induction  packs  and  training  is  provided  to  all  new  staff  on  how  to 
access  medical  needs  information  on  the  pupil's  SIMs  record.  All  staff  are  also  offered 
training  with  Compass Wellbeing  on  basic first  aid.  All  staff are  required  to  sign  to  confirm 
they  have  read  and  understood  key  policies  in  relation  to  medical  needs  and  safeguarding. 
The school has also devised roles and responsibilities charts for key polices, such as: 

• 
• 
• 
• 
• 

Supporting students with medical needs 
Safeguarding and Child Protection 
SEND policy 
Trips and Visits 
Asthma Awareness policy 

The  school  extended  this  support to  children  in  transition,  i.e.  those  moving  into  the  school 
from  Year  6  and  in  year  admissions  from  other  schools.  Staff  use  opportunities  such  as 
school visits  and  induction  days to request medical  information from  parents and  the  child's 
current  school  records.  This  information  is  shared  with  Compass  Wellbeing  so  IHP  and 
medication  requirements  can  be reviewed  over the summer holidays  and are in  place  at the 
start of each school year.  This also protects against any gap in  IHP or medication reviews. 

In  addition,  all  lHPs are being  scanned and attached to the  relevant child's electronic record 
(the  SIMS  profile)  so  that  it can ·be  viewed  quickly  by  staff.  An  alert  symbol  has  also  been 
added  to  relevant pupils'  SIM  profiles  so  that it is  immediately visible  if a child  has  an  IHP. 
Alerts  have  also been added  to the  school's Cashless Catering  System to flag  students with 
allergies  so  that  kitchen  staff are  aware  of those  children.  Catering  staff are encouraged  to 
liaise with  the relevant pastoral team or Compass Wellbeing to check if unsure and continue 
to challenge if they feel a pupil's choice may place them at risk. There is also a procedure for 
catering staff to report concerns where children with allergies regularly seek to purchase food 
containing allergens. 

The  school's  SENDCo will  provide briefings to  all staff for children. with  medical  needs each 
September. Further briefings will be  provided to all staff if a child with medical needs starts in 
year  and  all  new staff receive  the  briefing  as  part  of their  induction  if they  do  not  start  in 
September or if a child's needs change following  a review.  All staff received a briefing  on the 
pupils  with  medical  needs  on  the  05.06.17  and  will  receive  half-termly  reminders.  Those 
reminders  will  also  require  they  review  their  1class  context  sheets'  to  ensure  medical 
information  for  students  is  up  to  date.  The  Safeguarding  Committee  will  undertake  spot 
checks to ensure compliance, the_first of which will be completed by the 04.07.17. 

 4 

Since  the  Inquest the  Deputy  Head  teacher  responsible  for  safeguarding  has  reviewed  all 
information  held  in  respect  of children  with  medical  needs  to  ensure  that  the  IHP  register, 
Asthma  Register,  Allergies  Register  and  Other conditions  register is accurate.  The  registers 
are  now discreetly  displayed  by  type  of need,  the  pupil's  name  and  photograph,  symptoms 
and  key  actions  in  each  of the  staff common  areas,  the kitchen,  learning  support areas  and 
internal exclusion room. These are reviewed and updated on a half-termly basis. 

A fourth  issue identified by the Coroner was that not everyone involved in trying to  help Nasar 
was first aid trained. This is correct,  however,  there is no  requirement that all school staff are 
first  aiders.  The  'First  aid  in  schools'  guidance6  is  explicit  that  it  is  not  a  condition  of  a 
teacher's employment contract that they provide. first aid.  It is a matter for individuals whether 
they wish to volunteer for those responsibilities,  though as an employer a school's Governing 
Body must ensure that they have sufficient first aiders to provide first aid for school staff. The 
Health  and  Safety  Executive  (1HSE']  advises  that  organisations  such  as  schools  consider 
possible  risks  to  pupils  and  visitors  within  their  risk  assessments  and  allow  for  this  when 
determining the  number of first aid  personnel  they may  require.  It is  important to  clarify that 
the  school  does have  an  appropriate  number of first aiders  on  site  at all  times,  including on 
the  10.11.16.  Furthermore, whilst it wasn't referenced  within  the  narrative determination, the 
school's  arrangements  to  safeguard  students  was  subject  to  review  by  OFSTED  on  the 
17.11.16  and  found  to  be  effective,  in  particular  OFSTED  commended  the  rigour  of  risk 
assessments for school trips. 

Within  her  narrative  determination  the  Coroner  recognised  that  the  learning  assistant 
responded  immediately when  Nasar said  he  was  unwell  and  that a  first  aider was with  him 
within  20  seconds.  She  reported  that  the  first  aider  made  preliminary  checks  with  Nasar, 
including  asking  him  if he  had  pre-existing  conditions  or had experienced  symptoms  before 
and  then  rang  for an  ambulance  and  sought their advice  on  how to  best assist  Nasar.  The 
Coroner  also  noted  that  a  second  first  aider  attended  within  two  minutes  and,  recognising 
that he did have a pre-existing condition, requested his IHP (and,  by implication, medication). 

The Coroner rightly  recognised  within  the  narrative determination this was 'a very pressured 
situation'.  She  queried  whether  staff  may  have  responded  differently  if they  had  received 
training  or,  for those who  had, whether they may benefit from additional first aid training.  It is 
important  to  highlight  that  staff  administering  first  aid  are  not  expected  to  perform  those 
responsibilities  to  the standard  of care that clinicians trained  to  perform emergency  medical 
interventions are held to.  The  guidance simply  requires that staff use  their 'best endeavours 
to  secure  the  welfare  of  the  pupil'.  It  is  understood  that  the  Coroner  did  not  intend  her 
comments  to  be  taken  as  a  criticism  of the  actions  of staff on  that day.  To  do  so  may  well 
have  an  unintended  consequence  of deterring  otherwise  willing  volunteers  from  taking  on 
these  vital  responsibilities.  She  recognised  staff  had  responded  immediately  and  sought 
appropriate  advice  on  administering  the  EpiPen  from  the  London  Ambulance  Service 
operator  and  paramedic,  but  were  not  instructed  to  do  so  because  the  classic  signs  of 
anaphylaxis were not obvious.  The outcome, despite the staff best endeavours, was tragic in 
this  instance.  The  school  appreciates  that  publishing  this  report,  alongside  those  from  all 
agencies asked to respond to the Coroner's concerns, offers a further opportunity to publicise 

8 Issued by the Department for Education In 2000,  available at 
https://www.gov.uk/governmenUuploads/system/uploads/attachment_data/file/306370/guldance_on_flrst_aid_fo 
r_schools.pdf 

 .. 

5 

the potential  lifesaving  messages around  use  of EpiPens  in such circumstance  and we fully 
endorse this. 

The  school  is  also  grateful for the  opportunity  this  report  affords them  to  provide  assurance 
that staff and pupils have been offered additional first aid training and to  report that the whole 
school  community  have  embraced  those  opportunities.  A  further  25  members  of staff have 
volunteered  to  complete  a  first  aid  training  course  approved  by  the  HSE  over  the  next 
academic year,  many have already completed  their training  including  all staff responsible for 
supervising  internal  exclusion  room.  The  safeguarding  committee  have  devised  a  first  aid 
training  plan,  which  was  presented  to  and  approved  by  the  Governing  Body's  standards 
committee  on  the  14.06.17. This ensures  that  staff supervising  areas  of small  group  work, 
learning  assistants  and  those  who  lead  in  higher  risk  subjects  (e.g.  PE,  technology  and 
science)  are  prioritised for HSE first aid  training.  First aid  training  programmes are added  to 
the calendar at the start of each academic year, with staff identified for each course. This can 
only  be  amended  on  the  authority of the  Headteacher.  In  addition,  those  who  have  already 
completed  their  HSE  first  aid  programme  will  receive  an  additional  one-day  training  on 
asthma,  allergies  and  Epi-Pen.  This  is  in  addition  to  the  first  aid  training  at work  refresher 
courses. 

Those  members  of  staff  who  have  already  completed  a  HSE  approved  first  aid  training 
course  will,  from  September 2017,  meet monthly with  the  school  nurse to  share  information 
and  review  latest  advice,  guidance  and  practice.  The  school's  half-termly  safeguarding 
bulletins  contain  an  updated  list of all  first  aiders  in  the school  and  they  have  agreed  to  run 
regular briefings for staff at the  start of each half-term. They will  also  run  briefings for pupils 
on  a rolling  programme so that there  is increased awareness of who  on  the  staff team  have 
first aid  training. 

On  the 05.06.17 a member of the Governing Body who is also a GP provided a briefing to all 
staff on  the policy and procedures for supporting students with medical needs .. He explained 
how  to  identify  Asthma  and  Anaphylaxis  symptoms  which  indicate  medical  needs  were 
escalating  or becoming  critical  and  how to  respond.  This  briefing  is  due  to  be  repeated  in 
September 2017. 

To  raise  awareness  more  widely  across  the  school  posters  have  been  placed  in  all 
classrooms and throughout the school, including in the dining pavilion. These detail the steps 
to  take  where  someone  is  having  an  asthma  attack  or  allergic  reaction.  Allergens  posters 
continue to be placed at key sites within the dining pavilion and menus will be annotated with 
all allergens,  not just at Bow School but in  all schools supplied  by the  catering provider. The 
Executive  Headteacher is  working  closely  with  the  catering  provider to  ensure  that catering 
staff are  trained  and  aware of their responsibilities within  the school's policies and  has  been 
assured that the annotated menus will be in place by the beginning of September 2017. 

On the  11.07 .17 the Deputy Head will meet with 
 of Anaphylaxis Campaign, an 
awareness  raising  charity,  to  discuss  how  the  school  could  support  the  work  of  their 
campaign and  raise awareness more generally.  Thereafter, on the 13.07.17 pupils will  not be 
required  to  follow their usual  timetable,  instead  there  will  be a  themed  day of activities and 
learning  opportunities on  healthy living. As part of this staff will  be  raising  awareness of what 
pupils  can  do  to  support  students  with  medical  needs.  The  PSHE  curriculum  will  include 
medical needs awareness lessons. Year 9 pupils will be offered first aid training  in July 2017, 
this will  be extended to all pupils in the next academic year. 

 We  trust  these  actions  will  ensure  that  o,ur  whole  school  community  is  equipped  to  fully 
support children with  medical needs  and  respond  effectively if a  medical emergency  arises. 
We  remain  committed  to  working  with  the  wider  educational  networks  and  services  to 
improve  outcomes  for those  children  with  medical  conditions  and,  above  all,  hope that  the 
steps we have taken offer some comfort to Nasar's family and friends. 

6 

Interim Associate Head teacher

bsaci 

improving allergy care 

through education, training and research 

British Society for Allergy and Clinical Immunology 
Studio 16, Cloisters  House, 8 Battersea Park Road,  London SWB 4BG 
Tel:  +44 (0) 207 501  3910
Fax: +44 (0) 207 627 2599 
Email: info@bsaci.org 
Website:  www.bsaci.org 

To: Coroner M E Hassell 
Senior Coroner 
Inner North London 
St Pancras Coroner's Court 
Carnley Street 
London 

IC 4PP 

13 JUL  2017 

Rcgulntion 28:  Prevention of Future Deaths Report: 
Re:  lnqucstintothedcath ofNasarAHMED (d icd  14.11.1 6) 

I 

Tuesday July 11th. 2017 

Thank  you  for  forwarding  a  cop}  of the  investigation  into  the  death  of  asar  Ahmed.  You  have  asked  me.  as  President  of 
BSACI. to respond to your report and to set out details of action taken or proposed to be taken  in response to your report. 

The British Societ)  for Allergy and Clinical  Immunology (BSACI) is  the  society that  represents professionals who  work  within 
the  field  of Allergy  in  the  UK.  BSACI  has  a  long  track  record  of providing resources  10  both  our members and  to the  wider 
professional  community to support practice in dealing with allergic conditions.  The circumstances around Nasar's death are 1101 
novel  to this Society and, therefore, for many years we have  provided guidance in  order 10  reduce the risk  of similar cases in  the 
furure. 

We  have  produced a number of national guidelines using a  process accredited  by N JCE (National Institute of Care  Excellence) 
and these include the following: 

I.  BSACI Guidelines for the Management or Egg Allergy (20 I 0) 
2.  BSAC I Guidelines for Diagnosis and Management of Cows Milk Allergy (2014) 
3.  BSACI  Guidelines on Adrenaline Auto-injectors (20 16) 
4.  BSACI Guidelines on the Diagnosis and Management of  ul  Allergy (2017) 

In  addition.  we  have  promoted 1he  use  of wriucn  personalised  emergency 111anagcmcn1  plans  for  anaphyl~ctic  reactions.  We 
have developed templates  which  can be  used  by all  hcallhcare  professionals  available on  the  BSACI wcbstte and  these  can  be 
tailored to each individual 's personal circumstances and allergies. 

· 

· 

BSACI have  also been pa11  of a campaign  10 ensure  that  schools cnn  hol?  _spare adreln~linc  aAuto~Onjl~cto~;\~:~:1~1~/~~:~:!'i:~: 
-· 
k/:d/  ko '/2017/7 15)  The  revised  regulations  will 
for  use  in  emergencies.  This require  an  amen  men 
. 
week  that  the  amendment  has  been accepted  (hnp://www.leg1slat10n.~ov.u I" •  u 
-injectors .without  prescri1ltion  for  use  in
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come  into  elTect  on  I  October ~0 17  an  _w1.  a. ow  sc 
.  vidcd  it  is  done  on  an  occasional basis  and  not  for  pro ht. 
emergencies  from  a  pharmaceutical  supplier  Ill  small  qua~111tu.::  J)IO  I.  I  will  provide online  resources to suppon school  staff 
Furthermore  a working group  has  been  set up  10  develop  ,1  we  s11e  "  11c l 

1 10 the  Human  Medicines  Re0  u at1ons  Ct  -

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with this. 

. 

. 

.  th  sc  BSACI  initiatives  is available on www.bsaci.org.

Further mforrnat1on  on  e 
letter I would be pleased to speak to you. 

Ir you would  like to discuss the  contents of my 

With kind regards 
Yours sincerely 

President BSACI

l' compass wellbeing 

Compass Wellbeing CIC,  Steels Lane  Health Centre 

384-398 Commercial Road,  London El 0LR 

Tel: 0207 791 9441 

Fax: 020 7791 3669 

,.. 
Ir: 

13 JUL  2017 

Private & Confidential 

Coroner Ms ME Hassell 

Her Majesty's Senior Coroner 

Inner North London 

St Pancras Coroner's Court 

Carnley Street 

London 

NlC 4PP 

13 July 2017 

Dear Madam Coroner, 

Inquest into the death of Nasar Ahmed - Response to Regulation 28 Prevention of Future Deaths Report 

This is a response on behalf of Compass Wellbeing ('CWB') to your Regulation 28 Prevention of Future Deaths 

Report issued following the inquest into the tragic death of Nasar Ahmed. 

CWB have carefully considered each of the matters of concern raised  by you and this response addresses each 

concern  in turn setting out the action taken or proposed to be taken, along with a t imetable for the actions. 

The  purpose  of this  reply  is  to  set  out and  demonstrate  the  actions  taken  by  CWB  to  ensure  that  similar 

deaths do not occur in the future. 

Following the  death of Nasar Ahmed and  prior to the inquest commencing in May 2017,  CWB  undertook an 

internal investigation into the actions of the staff member directly involved, established core facts and sought 

to learn lessons from our failures and those of the School  Health Service to ensure as best we can  that those 

are not repeated. You may recall that one of our senior members of staff gave evidence to you and the family 

in  May about the steps that were  being taken and  we take this opportunity to answer your 4  questions and 

also update vou on the further action the organisation has taken. 

Steels Lane Health Centre, 384-398 Commercial Road, El OLR 
Registered in England: 08451249 

 
 l' compass wellbeing 

1.  When the school  nurse (employed  by Compass Wellbeing) conducted a review of Nasar's medication in 

May 2016, he did not have the medication stored  in school in front of him  at the time, but relied  on  its 

description by a school receptionist 

It  is  established  practice  that  at  each  child's  review  meeting,  all  of the  child's  medication  must  be 

physically  present and  visually  checked  by  the  school  nurse.  The  review  must then  be  recorded  in  the 

Child's Health Record and any action points followed up accordingly. 

It is  evident  from  an  investigation  carried  out  by  CWB  and  the  evidence  given  at the  inquest into  the 

death  of  Nasar  Ahmed  that,  on  this  occasion,  our  (Nurse)  staff  member  did  not  carry  out  a  visual 

inspection of the medication at Nasar's review meeting in May 2016. That is a matter of very deep regret. 

All  of CWB's  school  nurses  receive  'Health  Care  Plan'  t raining  as  provided  by  CWB  which  specifically 

covers the requirements for reviewing medicat ion and how and when this must be undertaken. The Nurse 

in this case attended that training in June 2015 and we have attempted to understand whether the failure 

was  an  individual  one  or is  wider.  We  have established  that the  Nurse  had  previously  undertaken  two 

periods  of  study  successfully  completing  a  practice  portfolio  demonstrating  a  knowledge  and 

understanding of reviewing medication during a Health Care  Plan  meeting. We therefore believe that the 

Nurse was fully aware of the requirement for medication to be physically present and visually inspected at 

a  review  meeting  and  he  should  have  done  so  in  May  2016  when  Nasar  Ahmed's  medication  was 

reviewed. 

Steps Taken 

We  have  reminded  all  of our staff that  there  are  no  circumstances  when  a school  nurse  would  not  be 

expected  to  have  the  medication  in  front  of them  when  conducting  a  review. Our  staff  have  been 

reminded that we would consider a similar breach to be an act of gross misconduct and  would also result 

in a professional conduct referral. 

To assist with ensuring that medication is visually inspected by school  nurses across the service at review 

meetings, a checklist has also  been  introduced for use during Individual Health Care  Plan  ("IHCP")  review 

meetings. This  new measure is designed to ensure that all areas of the review process have been  covered 

during  the  meeting.  This  new checklist  will  act  as  guidance  and  prompt to all  school  nurses  and,  once 

completed,  will  be  scanned  onto  the  Child's  Health  Record.  A  copy  of  the  'School  annual  review 

asthma/wheeze checklist' is enclosed. The completion of this checklist will form part of the bi-annual IHCP 

audit, further details of which are provided later in this response. 

Steels Lane Health Centre, 384-398 Commercial Road, El DLR 
Registered in England: 08451249 

 l' compass wellbeing 

As part of their investigations, CWB  have undertaken a wider review of the School Health Service, records 

kept  and  IHCPs,  all  of which  are  key  areas  in working  to ensure  that  IHCP  and  medication  reviews  are 

conducted correctly and in a t imely manner. 

In  December  2016,  CWB  carried  out  a  sample  audit  of IHCPs  to  review  a  cross-section  of IHCPs  and 

identify any areas that required improvement across the service. The findings showed that the IHCPs were 

of a good  standard  overall.  During  this  review,  there  were  examples  of high  standards of documented 

care however, it was noted that there was a lack of consistency across practitioners in terms of recording 

and  articulating details of care plan meetings. As  a result of this sample audit, it was identified  that there 

was  a  need  for a more robust approach ensuring that all  children requiring an  IHCP  have one that is  in 

date  and  fully and consistently detailing the support required;  including a particular focus  on identifying 

what action is to be taken in the event of an emergency. 

An  IHCP  improvement  plan  was  subsequently  implemented  to  identify,  review  and  monitor  all  IHCPs 

across  the  service  using  a  centralised  database.  This  will  support  the  identification  of  IHCPs  requiring 

review  which  will  be  automatically  flagged  to  the  senior  management  team  by  an  identified  data 

manager. The database  has  been  designed with a flagging system  in  it.  The  system counts down in days 

when an  IHCP  is  due  to be  renewed and turns the date yellow 60 days prior to the expiry date and  red 

once the date has arrived. The  database will be  managed  by a data  team on a daily  basis and details of 

IHCP  due  (within 60 days)  sent via email to the individual  nurse  responsible for the school and  their  line 

manager.  This  will  be  overseen  by  the  clinica l  lead  for  the  service  and  monitored  as  part  of the 

performance data for the service. 

A  full  Quality  Standards  Audit  was  commenced  in  June  2017  for  IHCPs  and  is  due  to  be  completed  in 

August  2017.  This  audit  will  review  all  IHCPs  across  the  whole  service.  Once  this  audit  has  been 

completed, the annual audit schedule will be extended to include IHCP audits on a bi-annual basis. We will 

put in place a robust action plan to deal with any deficiencies identified. 

CWB  has  also  fully  reviewed  and  identified  the training  received  by  school  nurses  and  what  they  are 

required  to  receive  in  order  to  complete  IHCPs  in  line  with  CWB's  Competency  Framework.  The 

Competency  Framework is  a learning and development resource  for nurses and  this  is  completed  upon 

their induction to the  service.  Re-training  has  been  delivered  in  line  with this Competency  Framework. 

IHCP training has also been undertaken by all staff on 22 June 2017 in order to re-emphasise the role of a 

qualified  nurse  with  reference  to  the  guidance  and  the  support  of administering  medication  by  non-

Steels Lane Healt h Centre, 384-398 Commercial Road, El OLR 
Registered in England: 08451249 

 l' compass wel lbeing 

registered (NMC) individuals. As part of the re-training exercise staff were told of the tragic events of this 

case. 

In  addition  to  the  above  training,  the  bi-annual  training  received  by  the  school  nursing  service  was 

delivered in June 2017. During bi-annual training, the service is suspended and training takes place across 

all staff groups. The training has  been tailored to support the key  learning points from the tragic death of 

Nasar Ahmed and  the requirements and  expectations of a school  nurse.  It covered a range of key areas 

including  how to  improve  record  keeping and  the  importance  of this,  the  increased  function of school 

nurse administrators in communication and following up actions with key staff in school and the parents, 

the use of electronic diary systems and diary management. A copy of the training schedule undertaken in 

June 2017 is attached. 

Specific  IHCP training will continue to take  place  on  a bi-annual  basis.  The  next scheduled  training is  for 

September 2017. 

We  believe  that  there  is  now  in  place  a  rigorous  and  proactive  approach  to  auditing,  reviewing  and 

monitoring  of IHCPs  and  we  are  determined  to  re-enforce  the  correct  medication  review  process  is 

followed by all of our staff. 

2.  Although  Nasar's mother was  present for the review,  there was  no  school  representative,  such  as  the 

year learning manager (head of year), there for the meeting 

CWB  recognises  and  understands the importance of the collaborative working arrangements involved  in 

preparing  IHCPs  and  the  ongoing  support,  communication  and  processes  for  children  in  schools  with 

medical conditions. The Supporting Medical Needs Policy clearly sets out that a number of organisations 

have roles and responsibilities and  that school  staff, school  nurses and  parents must work in  partnership 

to ensure that the needs of pupils with medical conditions are met effectively. 

Steps Taken 

Following  Nasar's  sad  death  CWB  have  prepared  a  Partnership  Agreement  between  CWB  and  schools 

across the Borough of Tower Hamlets. This agreement sets out arrangements for support and training for 

education  staff, as well as detailing the expectations across the organisational boundaries.  Page  7 of the 

Agreement  (copy enclosed)  outlines  the roles and  responsibilities  of the School  Health  Service  and  the 

school.  It specifically  requires  that a  member of staff will  be  identified  who  will  liaise  with the  School 

Health Service. The  identified  school  staff member is  the person  responsible  for that child  and  who  has 

Steels Lane Health Centre, 384-398 Commercial Road, El DLR 
Registered in England: 08451249 

 compass  wel lbeing 

the  appropriate levels of authority to agree possible actions generated from  an  IHCP  and  who is able  to 

disseminate  information  regarding  the  child's  care  across  t he  school,  including  what  to  do  in  an 

emergency. The  staff member will work to ensure support and  consistency is provided  by the school and 

School Health Service, particularly in relation to the creation of IHCPs and attendance at review meetings. 

CWB  is  currently  working  with  the  London  Borough  of Tower  Hamlets  Public  Health  and  Education 

departments,  as  well  as  Tower  Hamlets  head  teachers  representatives,  to  finalise  and  roll  out  the 

agreements across all schools. 

Alongside  this,  joint  letters  have  been  sent  to  all  school  head  teachers  within  the  Borough  of Tower 

Hamlets  detailing  how schools  can  become  "asthma  friendly".  This  also  out lines  the  expectations  and 

requirements of the school and the School Health Service. This has been prepared and sent in partnership 

with the specialist teams led by 

 (from whom you heard evidence at the inquest). 

Furthermore,  as  part  of  this  partnership,  CWB  with  the  assistance  of  the  respiratory  clinical  nurse 

specialist,  has revised  an  asthma  plan template for children and a process  for sharing individual  asthma 

plans with the school nursing service and  schools has been commenced. A child's individual asthma plan 

created  by  the  GP/practice  nurse or the specialist team  will now be sent  directly through  to  the School 

Health  Service via  secure generic email  accounts. These  email accounts  are  monitored  on  a daily  basis. 

The plan will be attached to the child' s health record and an email alert sent to the relevant school nurse. 

Training has been given to our staff team. 

In addition, school  nurses are  being supported to actively encourage appropriate members of education 

staff  in  the  schools  to  be  present  during  IHCP  meetings.  All  school  nurses  are  aware  of the  draft 

Partnership Agreement (see above)  which states that there is a requirement for a school staff member to 

be present at these meetings. With the support of senior managers, school nurses will work to encourage 

the presence of school staff in IHCP meetings. 

CWB has also initiated a Project Plan for an  incident  reporting system called the 'Radar Incident  Reporting 

System'. This  system  is  used  to  record  incidents  and  risks  within  the  organisation  and  also  highlights 

where  communication  difficulties occur,  including  where  IHCP  meetings  need  to  be  postponed  due  to 

non-attendance of education staff.  The  Radar Healthcare risk register will enable CWB to fully record and 

manage the major risks to the organisation and t he objectives that they compromise.  Risks are prioritised 

and  can  be  linked  to  existing  incidents  and  complaints  that  have  been  recorded.  The  system  allows 

regional  and  corporate  risk  registers to  be  managed,  with  actions,  alerts  and  reviews  being  tracked  to 

ensure effective risk management. 

Steel s Lane Health Centre, 384-398 Commercial Road, El OLR 
Registered in England: 08451249 

 l' compass wellbeing 

The automated workflow and alert system for each event type ensures that there is a consistent approach 

to reporting, recording and  managing events through the use of electronic event recording forms.  Once 

completed,  the  event  forms  generate  workflows  including  identifying  reporting  lines  and  governance 

arrangements and incorporating configured templates to help in performing effective investigations, root 

cause analysis and trend reporting. The project is being implemented in a number of phases which are set 

out at page 3 of the attached document. Phase 2 and the training on  the use of the Radar system is to be 

undertaken in August 2017 and it is expected that once Phases 3 and 4 are completed in early September 

2017, the system will be fully rolled out to all staff for use. 

These steps have been taken to ensure that all those involved in the effective care and support of children 

in  schools  with  medical  conditions  work  effectively  and  collaboratively  and  that  there  is  an  identified 

member of staff within each school to play a pro-active part in the preparation and updating of IHCPs and 

to attend review meetings. 

3.  The  school  nurse  then  updated  the  care  plan  by  using  the  allergy  action  plan  (mild-moderate  with 

asthma) instead of the correct one  used the year before allergy action plan (severe with asthma). This 

meant that Nasar's medication box contained an  EpiPen without any description of when or how to use 

it 

In  evidence  to you  the  Nurse  accepted  that  he  used  the  incorrect care  plan.  CWB's  investigation  has 

concluded that the Nurse had not reviewed  the previous IHCP from October 2014 marked "Allergy Action 

Plan  (Severe  with  Asthma)"  or the updated  April  2015  IHCP,  again  marked  "Allergy Action  Plan  (Severe 

with  Asthma)".  Both  of these  previous  plans  were  readily  available  to  the  Nurse  as  they  had  been 

uploaded  to the EMIS  (the electronic health record system} to which  he  had  access.  Paper records were 

also made available to him. When a school nurse is  preparing to review an IHCP,  it is established practice 

that they should go onto the EM IS and review the previous IHCP. This did not happen on this occasion. 

It has further been accepted by the Nurse that even if he did not have access to or see the previous plans, 

he should  have completed the "Allergy Action  Plan  {Severe with Asthma)" for Nasar Ahmed based  on the 

information he had available to him at the time. 

As  part of CWB's investigation,  each  of the  IHCPs  prepared  by this  Nurse at Bow School  were  reviewed. 

CWB's investigation found that other IHCPs prepared by the Nurse had errors in them and were r equire d 

to be re-written. That process has now been completed. 

Steels Lane Health Centre, 384-398 Commercial Road, El  OLR 
Registered in England : 08451249 

 Steps Taken 

l' compass wellbeing 

The Coroner is referred to the steps set out in response to the first concern raised and the processes that 

have  been implemented across the  service  to provide  assurances  in  relation to the  auditing, quality and 

consistency of IHCPs prepared and completed by school nurses. 

4.  He identified the  medicat ion  as  being  out of date, and asked that in-date  medication be provided,  but 

did  not diary forward to the following week to ensure that current medication was now in t he box.  This 

meant  t hat he also did not complete the action plan w it h t he dose of t he relevant medication 

The Supporting Medical Needs Policy indicates that the responsibility of checking that in-date medication 

is  provided  is  a shared one  between  the school  itself and the  school  nurse.  It  is fully expected  that the 

school  nurse  and  the  school  would  have  a  conversation  to  discuss  follow-up  actions  arising  from  a 

meeting  and  appropriately  diarise  to check  that  the correct  medication  has  been  received  and,  if not 

received,  to chase  this up in a timely manner. As a qualified health professional, the school nurse is able 

and  expected to understand  whether a prescription  is  appropriate  and  whether the correct  medication 

has been received. Any outstanding actions must be followed up and completed as a matter of course and 

in accordance with their professional duties. 

As  referred  to above,  CWB  has  carried  out an  investigation  into the  actions of the  Nurse,  including  his 

failure to diarise to ensure that the current medication was provided and in the box. As was evident from 

the Inquest, the investigation findings are that the Nurses' diary made no mention or record of any follow-

up  action  relating  to  checking  the  medication.  There  is  no  evidence  to  show  that  he  checked  the 

medication had been received and was in Nasar Ahmed's box and that is a matter of very deep regret. 

Steps Taken 

CWB  have  implemented additional  measures to ensure  that  the  checking  and  updating of actions  from 

IHCP  meetings are  routinely followed up by all school  nurses and  to prevent t his event from  happening 

again. 

All clinical  staff have  received  guidance on  how to manage  an  electronic  diary in  order to assist  staff in 

diarising  appointment,  reminders  and  sharing  calendar  appointments.  All  clinical  staff  have  access  to 

mobile  working  devices,  tor example  laptops,  and  the  service  is  moving  to  a  fully  electronic  diarising 

system  in order to support sharing of appointment calendars and the effective use  of an  electronic diary 

and  reminder system.  Specific  training on  electronic diarising and the  use  of this  took place  on 21 June 

Steels Lane Health Cent re, 384-398  Commercial Road, El OLR 
Registered in England: 08451249 

 ii compass  wellbeing 

2017 and  we believe that the system is fully understood by our staff team. The system will be fully rolled 

out in  the  new academic year (September 2017). Furthermore, the bi-annual  training referred  to earlier 

above will also cover the use of electronic diary systems and diary management and  act as a reminder of 

our  expectations. Having  an  electronic  diary  system  in  place  operated  by  trained  staff  will  enable 

appointments to be clearly made and  set out within the calendar and  reminders and  electronic prompts 

to be  set. This will assist in ensuring that actions are  followed up on a prompt and routine basis. We have 

told our staff that they should not be afraid of letting us  know if they are struggling to 'get to grips' with 

the electronic system of working. 

CWB  have  re-enforced  to  all  staff the  requirement  and  expectation  across  the  service  to  ensure  that 

accurate and  contemporaneous records are kept, including recording and  documenting action points and 

dates for follow up,  as  well  as  documenting who is  responsible  for each  action  point.  This  has  been  re-

enforced  through  medico-legal  training  which  was  arranged  for  all  staff  in  order  to  address  the 

implications  of poor documentation  keeping  and  the  effect this  has  on  the  delivery  of healthcare. This 

training took place on 19 June 2017. 

The  requirement and  importance of record  keeping is also  set out within CWB's Competency Framework 

which states that there is a need to "ensure all records are written contemporaneously and in accordance 

with  the  NMC  record  keeping  standard  and  local  record  keeping  and  documentation  standards  and 

guidelines  including  local  electronic  documentation,  storage  and  deletion  policies".  As  referred  to 

previously within this response, this is a framework reviewed and  completed by school nurses upon their 

induction  to  CWB.  Whilst  we  wish  to  avoid  repetition  we  confirm  that  training  in  relation  to  this 

framework and the relevant competencies has been re-run. 

We  hope  that  this  response  provides  clear  and  substantive  evidence  of  the  actions  taken  by  CWB  to 

prevent future deaths.  However,  should  you  require  any  further information  or clarification,  please  do 

not hesitate to contact us. 

Yours sincerely, 

CEO of Compass Wellbeing CIC 

Steels Lane Healt h Cent re, 384-398 Commercia l Road, El OLR 
Registered in England : 08451249

•Department 

of Health 

Office of the Chief Medical Officer 
Richmond House 
79 Whitehall 
London SW1A 2NS 

Ms Hassell 
HM Senior Coroner, Inner North London 
St Pancras Coroners Court 
Carnley Street 
London 
N1C 4PP 

Friday 7th  July 2017 

www.gov.uk 

Thank you for your letter of 12 May 2017 following the conclusion  of the  Inquest into the 
death of Nasar Ahmed. 

I was very saddened to read of the circumstances surrounding Nasar's death. Please pass 
my condolences to his family and loved ones. 

Your  Report  asked  if consideration  could  be  given  to  making  generic  adrenaline  auto-
injectors available in  public spaces,  in a similar way to that for defibrillators. This followed 
evidence heard at Inquest that the lifesaving potential of their use could outweigh the risks 
of harm in similar situations. 

In  giving  this  consideration,  I  have  taken  advice  from  the  Medicine  and  Healthcare 
Products  Regulatory Agency  (MHRA).  The  MHRA,  having  deliberated  on this,  considers 
such  an  action  could  pose  substantial  risks that  outweigh  potential for benefit  and  would 
need careful evaluation. The MHRA has both clinical and technical concerns. 

Clinical concerns 

Adrenaline  auto-injectors  are indicated  solely for the  emergency treatment of anaphylaxis 
and  are  intended  for  self-administration  by  the  patient,  their  carer  or  another  suitably 
trained  person.  Patients  known to be  at risk of anaphylaxis are strongly recommended  to 
times 
carry 
https://www.gov.uk/drug-safety-update/adrenaline-auto-injector-advice-for-patients  .  This 
recommendation  was  endorsed  by the European  Medicines Agency in  2015 following  an 
Article 31  safety referral: 

auto-injectors  with 

their  prescribed 

adrenaline 

at  all 

them 

 
 
 
 
 
 http://www.ema.europa.eu/ema/index.jsp?curl=pages/medicines/human/referrals/Adrenali 
ne  auto  injectors/human  referral  000367.jsp&mid=WC0b01ac05805c516f 

The  provIsIon  of  communal  adrenaline  auto-injectors  alongside  defibrillators  in  public 
places would require a member of the public to make a distinction between collapse due to 
anaphylaxis and  collapse  for other reasons,  including a  primary cardiac event such  as  a 
myocardial  infarction  or  an  arrhythmia.  The  importance  of  this  distinction  is  that 
inappropriate  administration  of  an  adrenaline  auto-injector  to  someone  suffering  from 
collapse for a primary cardiac reason  could  increase the likelihood of precipitating  a -fatal 
cardiac rhythm disturbance. 

Automated  defibrillators  (particularly  newer generation  defibrillators)  have  the  diagnostic 
capability  to  detect  the  presence  and  type  of  heart  rhythm  abnormality  and  whether  a 
shock  should  be  delivered.  Modem  defibrillators  are  equipped  to  deliver  shock  at  the 
appropriate  point in  the  cardiac cycle.  Adrenaline  auto-injectors  have  no  ability to  detect 
the cause of the collapse (anaphylaxis or other) and  therefore, the decision to  administer 
adrenaline will be dependent on the awareness of the public, an uncertain scenario. 

The  prescriber's  information for Epipen, and  the  Company's website, carry the following 
caveat;  "Use  with  extreme  caution  in  patients  with  heart disease ....  Cardiac arrhythmias 
may follow  administration  of adrenaline."  An  incorrect  choice  to  use  an adrenaline  auto-
injector  in  someone  suffering  from  collapse  due  to  a  heart  attack  or  other  cardiac 
disturbance could lead to fatal consequences. 

While it is recognised that during resuscitation for cardiac arrest, particularly for patients in 
asystole,  bolus  doses  of  adrenaline  are  used ,  for  tachy-arrhythmic  events  such  as 
ventricular  tachycardia,  defibrillation  is  the  first  choice  treatment.  Any  unintended, 
inappropriate  administration  of  adrenaline  could  precipitate  a  fatal  arrhythmia  and  will 
therefore  require reliance  on  a  considered judgement.  Provision  of adrenaline  alongside 
defibrillators  may  introduce  an  additional  decision  step  about  which  treatment  to 
administer.  Furthermore,  administration of adrenaline  in  cardiac  arrest  is  currently  under 
review, due to uncertainty over benefit-risk. 

Automated defibrillators have the important safeguard that they only deliver a shock if this 
is  required.  The  UK  resuscitation  council  guideline  on  automated  defibrillators  states: 
"They are safe and will not allow a shock to be given unless the heart's rhythm requires it." 

In  summary,  the MHRA  consider that the  benefit-risk  of defibrillators  in  public  places  is 
clearly favourable  (in that the benefits outweigh the risks).  Conversely,  the  benefit-risk of 
adrenaline  auto-injectors  in public  places  is considered  to  be  unfavourable.  If adrenaline 
auto-injectors  are  made  available  alongside  defibrillators  in  public  places,  this  risks 

2 

 conflation  of their  use  for  "collapse"  with  potentially  fatal  consequences.  An  additional -
decision step may also deter or delay the appropriate use of a defibrillator. 

Technical and practical concerns 

I am advised that there are additional significant technical and practical challenges with the 
provision of adrenaline auto injectors in public places as outlined below. 

I. 

II. 

Ill. 

IV. 

The  adrenaline  auto-injector  devices  marketed  in  the  UK  each  have  different 
instructions for use and are intended to be used by patients or other suitably trained 
persons to enable correct deployment of the drug. Their use is not intuitive  and for 
an untrained individual seeking to provide emergency assistance, there is a risk that 
they may either inadvertently self-inject the drug or administer it incorrectly. 

The  adrenaline  active  substance  is  relatively  unstable  in  solution  and  particularly 
sensitive to high temperatures. All the adrenaline auto-injector devices have a short 
time  to  expiry  of 18 - 20  months  from  the  date  of manufacture  and  need  to  be 
protected  from  extremes  of temperature.  Above  25°c,  the  adrenaline  auto-injector 
may well  have  reduced  potency due to  increased degradation of drug.  In  freezing 
temperatures there is a risk of the drug solidifying making it unable to be delivered. 
Low temperatures  might also cause  the  device to  malfunction  (the devices should 
not be refrigerated). These failures might not be evident to the user. 

It  would  be  highly  impractical  to  provide  temperature-controlled  storage  units  for 
adrenaline auto-injector devices  held  in  public  places.  Even  if correctly stored,  the 
device  would  have  to  be  replaced  on  its  expiry  date  which  would  require  a 
responsible  person  to  monitor this.  Two  or more devices  would  have  to  be  made 
available in case needed, introducing further complexity in storing them. 

The adrenaline auto-injector devices are marketed in three strengths (150, 300 and 
500  micrograms)  and  with  differing  needle  lengths.  The  prescribing  physician  will 
have determined the type of adrenaline auto-injector and strength as appropriate for 
an  individual.  In  public  places,  there  is  a  risk  of  using  an  inappropriate  device 
potentially delivering  an  ineffective  dose  or an  excessive  dose  depending  on  the 
circumstances. 

Permitting  adrenaline  auto-injectors  to  be  made  available  in  public  places  would  also 
require a change in the law and therefore a formal review and public consultation process. 

Based on  the complexities involved  in the appropriate use of adrenaline auto-injectors,  in 
the clinical  situations described  above  and taking  into account the technical and  practical 

3 

 issues  outlined,  the  MHRA  does  not  recommended  that  adrenaline  auto-injectors  are 
stored in  public places in the same way as defibrillators.  On the basis of this advice,  I am 
not currently  intending to  pursue further the  making  of generic  adrenaline  auto-injectors 
available in public places. 

However,  I  am  hopeful  that  work underway  to  change  the  law to  allow  schools  to  hold 
spare auto-injectors without a  named  individual  prescription, for use  as emergency back-
up to  treat anaphylaxis in children registered by the school as being in receipt of a medical 
prescription for an auto-injector, will tackle some of the challenges which staff faced in this 
sad case, and which were set out in your determination. 

Our amendments to  the  Human  Medicines  Regulations 2012,  Parliament  permitting,  will 
come  into effect on 1 October 2017. Officials are currently working on guidance for school 
staff in how to obtain and use these auto-injectors appropriately, and the guidance will also 
provide  advice  on  use  of  adrenaline  more  generally.  Clinicians  from  the  Anaphylaxis 
Campaign, as well as lay people, are advising on the content of this guidance, and we are 
hoping to also bring together training videos on different auto-injectors in a single website. 

I hope that this guidance, which we will bring to the attention of schools, will greatly reduce 
the likelihood of a  repetition  of the tragic events which led  to  the death of Nasar Ahmed, 
and so save other lives. 

Thank you for bringing the circumstances of Nasar Ahmed's death to our attention. 

CHIEF MEDICAL OFFICER 

4

Coroner Mary Hassell 
HM Senior Coroner 
Inner North London 
St Pancras Coroner’s Court 
Camley Street  
London 
N1C 4PP 

Dear Ms Hassell  

Legal Services 
Headquarters 
220 Waterloo Road 
London 
SE1 8SD 

Tel: 0207 783 2001 
Fax: 0207 783 2009 

www.londonambulance.nhs.uk 

13 July 2017  

Regulation 28; Prevention of Future Deaths Report arising from the inquest into the death of Nasar AHMED 

Thank you for your Regulation 28 Report dated 21 April 2017 bringing to my attention matters of concern.   

As there had been no concerns raised with the London Ambulance Service NHS Trust (LAS) prior to the inquest 
we were surprised and disappointed to receive this Regulation 28 Report.  

I note the concern raised is stated as follows:  

While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about 
whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think 
because the classic signs of anaphylaxis were not obvious.  

It is unfortunate that LAS were not made an Interested Person for the inquest and as a result we did not 
receive the benefit of full disclosure of documents.  LAS were also not asked to provide any information or 
documents relating to call handling or to confirm what advice had been given by the Clinical Hub paramedic 
nor were we informed of any concerns in this respect.   

Had we been given this opportunity we would have been able to provide you with the necessary information 
and we would also have offered the court a senior clinician to provide evidence at the inquest to clarify exactly 
what advice was given by the Clinical Hub paramedic and why, which I believe would have been of benefit to 
the court and Nasar’s family in the circumstances.   

Please find attached a transcript of the call CAD 2463 from 10th November 2016.   

It is clearly documented in the transcript that the caller from Bow school was unable to provide to both the LAS 
call handler and the Clinical Hub paramedic details as to what Nasar’s clinical condition was.  

Page 2 of the transcript confirms that the caller informed the call handler that they had an EpiPen and it had 
just been used.  

The call handler repeatedly asks the caller to advise what Nasar’s condition is and the caller is unable to 
provide clear details on whether he had allergies or asthma. As a result the call handler correctly seeks the 
assistance of a paramedic on the Clinical Hub, as call handlers are not clinicians. The handover from the call 
handler to the Clinical Hub paramedic detailed on page 4 of the transcript, details the call handler explaining to 

1 

 
 
 
 
 
 
 the Clinical Hub paramedic that the caller is not able to say what Nasar’s condition is and that they are 
requesting advice on the use of the EpiPen.  

On page 5 you will note that the paramedic takes the caller through a series of questions to determine with as 
much clarity as is possible when one is not on scene with the patient, what Nasar’s history was and his clinical 
presentation at that time.  

At no point does the paramedic advise the caller not to use an EpiPen. 

The conversation between the caller and the Clinical Hub paramedic lasts for less than one minute and before 
the Clinical Hub paramedic had finished asking the necessary questions, the ambulance crew arrived on scene 
and the Clinical Hub paramedic correctly left Nasar in the care of the on scene crew. 

I note from the Regulation 28 Report that the opinion given by the respiratory paediatrician who gave evidence 
at the inquest was that the correct and potentially lifesaving course of action, regardless of the particular 
constellation of signs and symptoms, is to use the EpiPen and to use it immediately.  

Given that the Clinical Hub paramedic was not clear on Nasar’s condition or when Nasar had last had the 
EpiPen, if at all, it was not unreasonable for the Clinical Hub paramedic to spend a few moments trying to 
establish the facts. The process of eliciting the necessary information was almost concurrent with the first 
paramedic arriving on scene. 

The audio recording of the inquest has been listened to by our Legal Services Department and I am advised that 
the evidence of the staff at Bow School was that they asked the LAS (call handler and Clinical Hub paramedic) if 
they should give the EpiPen but they did not get an answer. This is rather different to being told not to use an 
EpiPen, which was not the advice given by LAS. 

It is our conclusion that the call was appropriately managed by the call handler in trying to elicit the necessary 
information and it is clear from the transcript provided to you that the Clinical Hub paramedic did not advise 
Bow School not to use the EpiPen.  

I hope that this reply will be helpful in clarifying the confusion over the advice given by the LAS on the use of 
the EpiPen. On the basis of the reasoning set out in this response, LAS propose to take no action in respect of 
the concern raised in the Regulation 28 Report.  

This  Regulation  28  response  will  be  shared  with  the  Association  of  Ambulance  Chief  Executives  and  the 
National Ambulance Service Medical Directors. 

Finally in closing, I should like to offer my sincere condolences to Nasar’s family. 

Yours sincerely  

Chief Executive Officer 

2

St Andrews Health Centre 
2 Hannaford Walk 
London, E3 3FF 
Tel: 020 8980 1888 Fax: 020 8980 2753 
http://www.bbbhp.co.uk  

02-Jul-2017  

Coroner ME Hassell 
Senior Coroner 
Inner north London 
St Pancras Coroners court 
Camley Street 
London 
NC1 4PP 

Response to the Prevention of future deaths report following the death of Nasar Ahmed 

I am writing to you on behalf of Bromley by Bow health partnership in response to the 
matters of concerns raised by the coroner’s inquest in the 'prevention of future deaths 
report' following the death of Nasar Ahmed. 

We have been deeply saddened by the events and death of this child and the impact it will 
have had on the family- our thoughts are with them. 

Following the events that have occurred, these are just some of the steps we have taken: 
- We have discussed the case multiple times as a team and taken steps as a team to identify 
areas of good practice and areas for learning.  
- We have discussed the case individually with all those involved in Nasar's care (nurses, GPs, 
clinical pharmacist) and each consultation has been thoroughly reviewed. 
- We have contacted the pharmacy he collected medication from to discuss the matter and 
improve our understanding.  
- We have been in contact with the borough safeguarding team to provide information in 
order to support discussion at the serious case review panel for further learning.  
- We have also been in contact with the hospital paediatric respiratory team to arrange a 
meeting for further learning.  

I will now specifically respond to the 4 main points raised in turn. 

Partnership     

The Bromley by Bow Health Partnership 
Creating Healthy Communities 

 
 
 
  
 
          
 
 
 
                          
 
 
              
 
 
             
 
 
             
 
 
 
                              
 
 
                                  
 
   
 
                        
 
  
 
          
 
 
 
 
 
 
 
 
 
 
 
 
 
 St Andrews Health Centre 
2 Hannaford Walk 
London, E3 3FF 
Tel: 020 8980 1888 Fax: 020 8980 2753 
http://www.bbbhp.co.uk  

Point 1 states that Nasar's report of symptoms to his consultant didn't correlate with the GPs 
findings, that his lung function tests were good, that GP prescribed 30 inhalers which is a 
recognised risk factor for death and that he should have been seen by the consultant again. 
The point queries whether an automatic flag could be raised if excess medication is 
prescribed. 

There is already a mechanism in place via our Emis patient records system which flags a pop 
up alert anytime excess short acting beta agonist inhaler prescriptions are given- this is if 
more than 12 are issued in the last 12 months. The patient is flagged as high risk and if we 
haven't already, we would contact the patient/parent to book in for an asthma review. 

These patients also get flagged up on our recall list for ‘enhanced asthma review’. We 
currently run searches for those deemed as high risk patients (i.e. those that have a high use 
of SABA inhalers more than 6 per year, more than 2 asthma exacerbations per year, recent 
hospital or A&E attendance or high dose inhaled steroid therapy) and proactively invite 
these patients for review as a priority for enhanced asthma reviews. 

Nasar was proactively invited for an enhanced review as he was flagged up in such a way 
demonstrating that the flag does pick up such patients. This review took place on 15th Feb 
2016 and this is where he was discovered to have poor inhaler technique. Time was spent 
teaching him the correct technique for his preventer and reliever medication. The report 
suggests he should have been seen by the consultant again. He did indeed get seen 5 days 
after this consultation in a consultant clinic. On 19th Feb he was seen by a specialist 
registrar. We believe that the registrar did not flag him up as a high risk patient because 
following the correction of his inhaler technique by our team, his symptoms and lung 
function tests were much better. He had further follow up appointments organised by us 
after this in March and it did in fact show that his asthma control score had improved to 
24/25. Nasar was invited again in August 2016 proactively for another enhanced asthma 
review. Our notes indicate that our recall team called the family and reminded Dad the day 
before that Nasar had an appointment for the on 31st august. The clinician conducting the 
consultation also called prior to the appointment to remind family to bring in inhalers so that 
inhaler technique could be checked again, unfortunately, these were forgotten by the family 
and so a note was made by the clinician that the inhaler technique needs to be checked 
again at next follow up. At this point, the Asthma test score was again 14/25. There was no 
specified time period for follow up or review. However, there was a further entry on 14th 

Partnership  

The Bromley by Bow Health Partnership 
Creating Healthy Communities 

 
 
 
 
 
 
 
 
 
 
 
                 
 
      
 
 
    
 
                      
 
            
 
              
 
     
 
                   
 
 
  
 
 
 
 
 
 
 St Andrews Health Centre 
2 Hannaford Walk 
London, E3 3FF 
Tel: 020 8980 1888 Fax: 020 8980 2753 
http://www.bbbhp.co.uk  

October 2016 in the notes where we contacted the parents to come in for a medication 
review with a GP. 

On review of the literature, there is no specified guidance about what actions should be 
taken with different levels of asthma test scores- just that a score less than 20 may indicate 
poorly controlled asthma. Further national level guidance on this may be useful to avoid 
variations in action. At a clinical team meeting on 27th June 2017, we reflected on the point 
that at Nasar’s August 2016 asthma review, there was no follow up specified for the patient 
on finding that his asthma test score was 14/25. It was agreed that all clinicians must 
document specified follow up if the asthma test score is found to be suboptimal (i.e. 
<20/25). Who this review should be with and how soon it should take place would be agreed 
with the patient/parent on a case-by-case basis. This will be implemented immediately i.e. 
from June/July 2017. 
We hope this addresses all the queries raised in point 1. Whilst we believe our processes 
work well, following the event we have taken steps to tighten these even further. 

Point 2 states that the asthma pump in Nasar's medication box was an accuhaler which is 
inappropriate for an emergency situation and that the appropriate inhaler should have been 
prescribed with a spacer. You wonder whether there is a wide spread lack of understanding 
about this. 

As a team, we have reviewed national and local guidance around appropriate prescriptions 
of inhaler devices. We have discussed this with nurses, specialist pharmacists and the rest of 
our clinical team. The guidance suggests, and widespread practice is, to prescribe the inhaler 
type that best suits the child. In Nasar's case this was an accuhaler. We could not find any 
guidance that those prescribed an accuhaler for preventer use should also be prescribed a 
metered dose inhaler with an aerochamber to be kept at home/school for emergencies. 
Furthermore, throughout all his specialist hospital reviews, this was not a suggestion made 
by our paediatric respiratory specialists.  

We reviewed  BTS/Sign guidelines 2016 and the national review of asthma deaths audit 
2014. BTS/SIGN (2016) stated: 

Specific evidence about the pharmacological management of adolescents with asthma is 
limited and is usually extrapolated from paediatric and adult studies. Specific evidence about 
inhaler device use and choice in adolescents is also limited.   

Partnership  

The Bromley by Bow Health Partnership 
Creating Healthy Communities 

 
 
 
 
 
 
 
 
 
 
 
                 
 
      
 
 
    
 
                      
 
            
 
              
 
     
 
                   
 
 
  
 
 
 
 
 
 
 
 
 St Andrews Health Centre 
2 Hannaford Walk 
London, E3 3FF 
Tel: 020 8980 1888 Fax: 020 8980 2753 
http://www.bbbhp.co.uk  

INHALER DEVICES- Adolescent preference for inhaler device should be taken into 
consideration as a factor in improving adherence to treatment.  As well as checking inhaler 
technique it is important to enquire about factors that may affect inhaler device use in real 
life settings, such as school.  Consider prescribing a more portable device (as an alternative to 
a pMDI with spacer) for delivering bronchodilators when away from home. 

On discussion we felt that it may be an expert opinion to additionally prescribe another 
inhaler with an aerochamber for emergency situations such as this but there isn't any 
broader local or national guidance that recommends this and if this is the most appropriate 
action, this needs to be highlighted at national level to feature in guidance so that systemic 
change can take place both within general practice but also at hospital level. 
We agree that an accuhaler is not suitable for an emergency situation where a patient may 
not have enough respiratory effort to take in the medication appropriately so as a practice 
we agreed that for patients using accuhalers, we would issue an MDI with spacer for use in 
emergencies and make it clear what this is for in the asthma review. This will be 
implemented from July 2017. 

Point 3 suggests that there must be a way of ensuring that a school care plan is accurate, up 
to date and that there are identical copies stored at home, school, GP surgery and within 
hospital records. 

We are currently in contact with our borough children’s safeguarding team to determine 
whether School nurses have access to the community version of our patient record system 
so that information about care plans can be input into this and this can be shared between 
us and the school nurses. Some hospital departments also have limited access to our patient 
record system- this may be a good way to share information. There needs to be borough 
wide (and national consideration around this). From a practice level, our clinical teams are 
checking for up to date and accurate care plans during asthma reviews- however, this case 
has further highlighted the importance of this.  

As a practice, we have agreed that our nursing team (who conduct the majority of our 
asthma reviews) will post/email a copy of the asthma action plan to the child’s school health 
team and/or a copy will be given to parents to hand into the school. This change will be 
implemented from July 2017. 

Point 4 asks if there is a way of disseminating info more widely around the appropriate 
indications and use of IM adrenaline. 

Partnership  

The Bromley by Bow Health Partnership 
Creating Healthy Communities 

 
 
 
 
 
 
 
 
 
 
 
                 
 
      
 
 
    
 
                      
 
            
 
              
 
     
 
                   
 
 
  
 
 
 
 
 
 
 
 St Andrews Health Centre 
2 Hannaford Walk 
London, E3 3FF 
Tel: 020 8980 1888 Fax: 020 8980 2753 
http://www.bbbhp.co.uk  

All our staff receives yearly BLS training and training around anaphylaxis. During this training 
the points above may or may not be emphasised by the trainer. We would share our 
learning around this at borough wide level with the safeguarding children team and discuss 
whether change can be implemented such that trainers organised to deliver this training 
emphasise the points highlighted if they also agree with these. By the end of September 
2017, our nursing team will investigate whether there are anaphylaxis care plans that are 
already in place and being used by secondary care. We will then be incorporating these into 
care plans when seeing patients with asthma and allergies who have adrenaline 
prescriptions.   

I hope all your points have been addressed. We are keen to work with all willing partners to 
improve the care of patients with asthma and will be happy to provide any further 
information as required. 

Regards 

GP Partner – Bromley by Bow health partnership 

Partnership  

The Bromley by Bow Health Partnership 
Creating Healthy Communities