Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0595, written 25 Nov 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Nov 2025 |
|---|---|
| Reference | 2025-0595 |
| Deceased | Benedict Blythe |
| Coroner | Elizabeth Gray |
| Coroner area | Cambridgeshire and Peterborough |
| Category | Child Death (from 2015) · Other related deaths |
| Organisation named | North West Anglia NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1 Royal College of Pathologists 2 Cambridgeshire Constabulary 1 CORONER I am Elizabeth GRAY, Area Coroner for the coroner area of Cambridgeshire and Peterborough 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 On 09 December 2021 an investigation was commenced into the death of Benedict Edward Falcon Blythe aged 5 years old. The investigation concluded at the end of the inquest on 09 July 2025. The conclusion of the Inquest Jury was that: “Accidental exposure to an allergen, cows milk protein, causing fatal anaphylaxis.” 4 CIRCUMSTANCES OF THE DEATH Benedict died at Peterborough City Hospital (PCH) on 1/12/21 as a result of food induced anaphylaxis; he was 5 years old at the time of his death. Benedict suffered from asthma and a number of allergies including a milk and egg allergy. He was under the care of the paediatric allergy team at PCH. PS in September 2021. On Benedict had started in reception year at 29 November 2021 Benedict was unwell overnight, he vomited twice, which was observed by his mother to consist of phlegm and was kept off school on 30 November 2021. He attended school as normal on 1 December 2021. At morning break time on 1 December 2021Benedict went outside with a group of other children to have his snack – a snack of biscuits which he had brought into school from home. He then returned to the classroom where he was offered a drink of which ought to have been of the oat milk provided to the school by his parents. Regulation 28 – After Inquest Document Template Updated 30/07/2021 Benedict’s oat milk was kept in a fridge in the school staff room separate from the individual cartons of cow’s milk provided to non-allergic children and together with a carton of lactose free milk provided to a child in Benedict’s class who was lactose intolerant. Benedict was reported to have decided not to drink the milk handed to him in his own cup/receptacle and poured it away. The Class Teacher accepted that she could not be certain whether Benedict had taken a sip of the drink when she wasn’t looking. Typically, the Class Teacher or a Teaching Assistant would collect the milk from the staff room at break time, pour oat milk into Benedict’s designated cup/receptacle, pour into a school provided cup/receptacle for the lactose free child, and distribute the individual cow’s milks cartons to the remaining children. the lactose free milk Shortly later Benedict was seen to have vomited. Benedict’s parents were contacted to come into school and collect him; he was cleaned by a Teaching Assistant and sat reading a book with the Teaching Assistant when he vomited again. Benedict was then escorted outside by the Class Teacher to get some fresh air and his parents were contacted to take him home. Shortly after Benedict went outside with his Class Teacher, he collapsed was carried back into the classroom. His Adrenaline Auto Injector (AAI) was administered by a first aid trained Teaching Assistant; a 2nd AAI was subsequently administered. Benedict was not responding and he was not breathing and CPR was started. Benedict’s father attended school and carried out CPR as did other teaching staff. The emergency ambulance crews and emergency helicopter medical attended. crew also Benedict was taken to PCH where he was declared deceased. Police attended the school and carried out an investigation within the classroom and school environment and took witness statements. Benedict’s vomitus was not seized as part of the Police investigation and no other investigatory authority requested the collection of data samples or preservation of evidence at the scene. At PCH the paediatric consultant requested that mast cell tryptase tests were done during the resuscitation efforts, to identify whether Benedict had suffered an anaphylactic reaction, and which confirmed that he had. investigations into Benedict's death focused on his consumption of a Initial McVitie’s biscuit which he had brought in from home, and which he ate at the break time in school before he vomited and subsequently collapsed. During Regulation 28 – After Inquest Document Template Updated 30/07/2021 the course of the investigation, it became evident that the Mcvitie's biscuit did not cause Benedict's anaphylactic reaction and that it was more likely than not that Benedict's anaphylactic reaction was caused by exposure to cow’s milk protein. The retention of samples and testing by pathologists would have assisted in identifying the cause of Benedict’s anaphylactic reaction at an earlier stage and may prevent future deaths. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise In my opinion there is a risk that future deaths could occur unless to concern. In the circumstances it is my statutory duty to report to you. action is taken. The MATTERS OF CONCERN are as follows: During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The matters of concern are as follows: 1) In relation to Pathology That Kennedy samples collected during a post-mortem examination, should be revised to include the following in cases of suspected anaphylaxis: blood samples for mast cell tryptase and sp IgE serology 2 suspected a. allergens stomach contents to be immediately stored (and/or frozen) by the b. pathologist for the analysis of the presence of the triggering allergen c. for testing blood samples if taken at hospital should not be destroyed but retained that an early blood sample is taken after death and stored for later d. analysis e. that the possibility that the death is due to anaphylaxis is raised with the senior coroner for the area where the death occurred at the earliest opportunity f. tissue samples are taken and retained. g. Consideration given to the development of a standard protocol to ensure appropriate samples are taken at the correct time to assist later investigation. Regulation 28 – After Inquest Document Template Updated 30/07/2021 2.) The police investigation: In the circumstances where there is an unexplained death of a child or the person and where that are data samples and evidence available at the scene including by way of example vomitus, that the police should include as part of their investigation, the seizure and retention of any such material for the purposes of later investigation either by the Police the Pathologist or the Coroner. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by January 20, 2026. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Family of Benedict BLYTHE – (Parents) Primary School Peterborough City Council Pladis North West Anglia NHS Foundation Trust Department of Education East of England Ambulance Service Regulation 28 – After Inquest Document Template Updated 30/07/2021 and to the Child Death Overview Panel. I have also sent it to – Consultant in Allery and Asthma who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Dated: 25/11/2025 Elizabeth GRAY Area Coroner for Cambridgeshire and Peterborough Regulation 28 – After Inquest Document Template Updated 30/07/2021
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Contact us: To: His Majesty’s Coroner. From: Detective Chief Superintendent Date: 12 January 2026 Benedict Blythe – Regulation 28 response Cambridgeshire Constabulary has undertaken a comprehensive review of its processes following the issues highlighted during the inquest into the death of Benedict Blythe. As a result, a series of improvements have been implemented to strengthen the policing response to sudden and unexplained child deaths, particularly where forensic opportunities may be relevant to establishing cause. First, full liaison with Scenes of Crime Officers (SOCOs) has been established to ensure that, in all cases of unexplained child death, the potential evidential value of samples found at the scene—such as vomitus or other biological material—is actively recognised and considered. SOCOs have been formally briefed, and the need to assess and seize such samples is now incorporated into the forensic strategy in consultation with the Senior Investigating Officer. This ensures that opportunities to preserve material for the Coroner, the Pathologist, or investigators are not missed. Second, the Constabulary has amended and re-issued internal procedural guidance and aide-memoire materials relating to child death investigations. These documents have been circulated widely to all officers and staff who may attend such incidents, 1 | P a g e reinforcing expectations around early evidence preservation, liaison with medical professionals, and the importance of raising potential anaphylaxis as a consideration where appropriate. Third, the updated guidance has been incorporated into the Protecting Vulnerable People (PVP) departmental newsletter, ‘SaferTogether’, ensuring that specialist investigators—who manage the majority of child death responses—are fully aware of the changes. Embedding these updates within existing communication channels supports strong organisational understanding and consistent practice across teams. Finally, the revised processes are now included within ongoing training cycles for child death investigations, meaning all staff involved in frontline or investigative roles will receive regular reinforcement of expectations and good practice standards. This training emphasises the forensic, investigative, and safeguarding considerations required in early decision-making, helping ensure that opportunities to understand cause of death are preserved and that future investigations are informed by best practice. Together, these measures demonstrate Cambridgeshire Constabulary’s commitment to learning from this tragedy and to ensuring that future responses to similar incidents are strengthened, consistent, and aligned with the concerns raised by the Coroner. 2 | P a g e
Ms Elizabeth Gray Area Coroner for Cambridgeshire and Peterborough 16 December 2025 Dear Ms Gray Re: Correspondence from Coroner's Service - Regulation 28 report - Benedict BLYTHE Thank you for your Regulation 28 Report to Prevent Future deaths following the inquest into the death of Benedict Blythe on 1 December 2021. We would like to extend our condolences for the family of Benedict and their loss. I am responding on behalf , Chair of the Prenatal, Perinatal and Paediatric Pathology Special Advisory Committee of the Royal College of Pathologists. Please see the response below: The Kennedy Protocol has not been formally updated since 2016 it is not known when or if the protocol is to be revised. Since then Autopsy guidelines have been published on sudden unexpected death in fancy and childhood in 2023 under the remit of the Death Investigation Committee at the Royal College of Pathologists and these have superseded the 2016 publication. Neither the 2016 or 2023 guidelines included samples in cases of suspected anaphylaxis. However, the RCPath published autopsy guidelines on autopsies for suspected acute anaphylaxis (includes anaphylactic shock and anaphylactic asthma) in 2018. This document does include very specific guidance of sampling blood and stomach contents in such cases together with caveats for interpreting mast cell trypase levels. Although the Paediatric guidelines do not currently include specific details regarding anaphylactic cases, it is expected that autopsy pathologists would be aware of and use other relevant autopsy guidance as indicated by the case being undertaken. There are guidelines published by the RCPath for anaphylaxis (referenced below) of note; IgE is not specifically referenced in any of the documents and this will be queried with the authors of the relevant guideline to be included in an updated version. The reference below was published after the guideline was written. Early blood sampling is indicated but timing may be determined by the local post-mortem HTA 2004 arrangements in individual hospitals. In addition, it is extremely difficult to obtain femoral vessel blood samples in very young children purely due to the size of the individual and blood may The Royal College of Pathologists 6 Alie Street, London E1 8QT Tel: 020 7451 6700, Fax: 020 7451 6701, www.rcpath.org Registered Charity in England and Wales no. 261035 have to be obtained from other sites such as the ventricles of the heart which can be problematic for interpretation of mast cell tryptase levels. In all Coronial post-mortem examinations in children, tissue samples are taken primarily in accordance with the published protocols and also any that are relevant to ascertaining the cause of death. Retention of samples is determined initially by the Coroner requesting the post-mortem examination and thereafter by parental / next-of-kin consent in line with the Human Tissue Act 2004. If a death due to anaphylaxis is suspected, this should be raised by the initial referring medical practitioner to the Coroner’s officer or by the police. The case to which the Coroner’s queries are raised should have anaphylaxis or allergic reaction in the potential cause of death or in the deceased’ situational history before the pathologist was contacted. It is usual practice for the autopsy pathologist to communicate a suspected cause of death to the Coroner after the initial examination pending the results of further investigations, however, it is not always possible for a pathologist to be definite at that stage. In summary: Post-mortem guidelines are in place for allergic / anaphylactic deaths. IgE is not currently in the protocol and this will be raised with the author group of the relevant autopsy guideline. Likewise, including a cross-reference to other autopsy guidelines will be raised with the author group of the paediatric autopsy guidelines. Consultant Paediatric and Perinatal Pathologist. Chair of the Prenatal, Perinatal and Paediatric Specialty Advisory Committee, Royal College of Pathologists. 9th December 2025 References: Kennedy protocol, 2e 2016: https://www.rcpath.org/static/874ae50e-c754-4933- 995a804e0ef728a4/Sudden-unexpected-death-in-infancy-and-childhood-2e.pdf Sudden unexpected death in infancy, 2023: https://www.rcpath.org/static/57243bdd-ee48-40ca- 8199540e77b29892/G191-SUDIC.pdf Autopsy in Anaphylaxis, 2018: https://www.rcpath.org/static/47841b6b-891f-450a- b968889ff3e0a7d1/G170-DRAFT-Guidelines-on-autopsy-practice-autopsy-for-suspected-acute- anaphalaxis-For-Consultation.pdf Confirming anaphylaxis post-mortem using serological tests, 2020: https://jcp.bmj.com/content/jclinpath/73/12/781.full.pdf Post-mortem tryptase: https://www.sciencedirect.com/science/article/abs/pii/S0379073820302772 2 Thank you for bringing this matter to our attention and please reach out if you need any further information. Kind regards Senior Professional Guidelines Officer 3
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