Anaphylactic reactions, lessons learned

A fifth of all fatal reactions occur while at school: This rise in serious anaphylactic reactions is a huge issue for schools, as they are responsible for the welfare of our children, whilst in their care. We are proud to be working with SAPHNA the Schools and Public Health Nurses Association to help schools provide the best possible care for children with complex medical conditions. We have created online courses, resources and specialist training to ensure schools have undertaken the necessary preparation should a child in their care experience a medical emergency.

How we can help
First Aid for Life can help schools to ensure they have everything in place for children with medical conditions:

• Provide help and templates for Individual Healthcare Plans
• Supply online and practical first aid training specifically for schools caring for pupils with complex medical conditions. These include anaphylaxis, asthma, diabetes, seizures as well as updates on medical emergencies such as head injuries and choking.
• Offer regular updates, infographics and posters to help schools communicate vital information to other staff and pupils.
• Assistance with managing emergency adrenaline autoinjectors and asthma pumps.
• Can help with specific advice for children with complex medical conditions or signpost schools to the best place to obtain that advice.
• Assist schools with systems to flag if medication is about to go out of date.
• We also run the full range of regulated and shorter courses for staff and pupils in schools.

Karanbir’s death and the Coroner’s findings:
Karan, was a 13 year old boy with a dairy allergy; he went from being fine, to unconscious within 10 minutes of his fellow pupils throwing cheese at him at his school. As a result, he sadly died 10 days later in Great Ormond Street Hospital.

The Coroner’s verdict apportioned some responsibility to Karan’s school for missed opportunities that might have changed the outcome: “Most importantly in terms of the potential to change the outcome, there was a missed opportunity by Karanbir’s school to raise awareness among their pupils of the grave nature of his allergies; care needed to be taken to avoid his contact with allergens.”

The coroner also described the school’s healthcare provision for Karan as “inadequate”. Karan had an “insufficient” care plan. He had only one Epipen in his medical box although his mother had said he needed two; there was also lack of a robust system for checking medication was in date.

The inquest heard that only one Epipen had been administered to Karan, and this was 11 months out of date. School staff said they had not given him a second Epipen because they thought a 10-minute gap was necessary between doses; the ambulance operator had not told them to do this.

Coroner findings:
The Coroner said: “It is impossible to to say whether the use of adrenaline that was in date, or the administration of a second Epipen would have changed the outcome, but they would have given Karanbir a better chance of survival.”

Another factor according to the Coroner was “the national lack of understanding about the necessity of giving an Epipen immediately after there are breathing difficulties”. She added that a second Epipen should be given five minutes after the first, or immediately in the event of a deterioration.

Karan’s reaction was extraordinarily rare
The coroner described Karan’s reaction to an allergen that was not ingested but only ever in contact with his skin, as “extraordinarily rare”.

Dr Adam Fox, a consultant paediatrician and leading expert on anaphylaxis, agreed with this. He stated during the inquest, that if skin contact alone had caused Karan’s fatal anaphylaxis, it would be unprecedented.

It is thought that Karan (who also had severe eczema and asthma) scratched at his neck drawing blood when hit by the cheese; this therefore broke the skin barrier and increased his exposure to the allergen.

The paramedic attending Karan did not realise he was experiencing an anaphylactic reaction until she was unloading him at Ealing Hospital.

Lessons need to be learned
Although no one could have predicted such an appalling outcome of a childish prank – schools do need to learn lessons from this and ensure that is does not happen again.

Vital information from the Coroner:
– If a person with an allergy is exposed to an allergen and develops any breathing difficulty at all, then someone should administer adrenaline (via EpiPen or other) immediately. This should be done before using an asthma pump and even before calling for help;

– Once there is a deterioration after giving one EpiPen, someone should administer another immediately; in any event after five minutes if there is no improvement.

Key decision makers received the Coroner’s verdict in the following report

Here is a summary of key findings and advice relevant to schools :

• Targeted information to staff and other pupils as to the nature of allergies and anaphylaxis. This would ensure everyone understands the consequences of exposure and how to help with a reaction.
• The importance of up to date and regularly reviewed Individual Healthcare Plans
• Someone should review medication in line with the IHPs and mechanisms in place to ensure they are in date. Adrenaline becomes increasingly less effective past its expiry date.
• People prescribed two Epipens should have both available to them at all times.
• The importance of giving adrenaline promptly – particularly if the casualty is struggling to breathe.

Matters of concern are as follows:
1. The pupils at Karanbir’s school had a patchy understanding of his allergies and of the consequences of exposure to allergens. Targeted education about this would improve safety.

2. Nobody had checked Karanbir’s school care plan and medical box. For example, they should check that if his care plan stipulated two EpiPens® (adrenaline auto-injectors) that the box contained two EpiPens.

3. Karanbir’s EpiPen was out of date. There must be systems in place to ensure that medication in schools is in date.

4. Allergy action plans should be standardised across hospitals and schools, so messages are as clearly delivered as they can be. This is vital particularly when people may read them for the first time in a desperate situation where panic has set in.

5. The allergy action plan drafted by Karanbir’s doctors at Ealing Hospital did not find its way to his school. There is no standardised approach to this; for example always sending a copy to the school designated safeguarding lead, as well as giving parents/carers a copy for themselves and a copy for the school in case the posted version does not arrive.

6. Karanbir had one EpiPen at home, one at school and one at his father’s home. There is clearly a need for medical teams to emphasise that two EpiPens must be available at all times.

Improve overall awareness of anaphylaxis
7. There appears to be a lack of awareness nationally of the simple but vital messages that:

– Once a person with an allergy has been exposed to an allergen and develops any respiratory compromise, or any breathing difficulty at all, then they should receive adrenaline (via EpiPen or other) immediately, before any asthma pump and even before calling for help;

– If there is a deterioration after giving one EpiPen, then another should be administered immediately, or in any event after five minutes if there is no improvement.

8. EpiPen boxes do not contain these instructions on the outside but they should

9.School staff’s first aid and EpiPen training should include instructions on the administration of EpiPens.

10. London Ambulance Service 999 operator did not at any time suggest that a second EpiPen be given, because this is not contained within the algorithm. That could be remedied internationally.

11. The allergy specialist who gave evidence was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.

This was the view of the respiratory physician who gave evidence in May 2017