Report on boy who died after allergic reaction 'overlooks systematic failures'
Benedict Blythe, five, died after accidental exposure to cow's milk protein at Barnack Primary School
The family of a five-year-old boy who died after an allergic reaction at school has criticised a coroner's prevention of future deaths (PFD) report as a "lost opportunity" that overlooks "systematic failures".
Benedict Blythe, five, died after accidental exposure to cow's milk protein at Barnack Primary School, between Stamford and Peterborough, in December 2021.
An inquest found the school did not follow all the measures in place to prevent the fatal anaphylactic reaction, and that there were risks of contamination and delays in administering an adrenaline pen.
In a prevention of future deaths report, coroner Elizabeth Gray outlined failings in the investigation into what caused Benedict's anaphylactic reaction.
It said initial investigations into Benedict's death focused on him having eaten a McVitie's biscuit that he had brought in from home on the day he collapsed.
It later became clear the biscuit did not cause Benedict's anaphylactic reaction, and an inquest found he had probably been given cow's milk protein in his bottle during break time.
Ms Gray said the failure to retain Benedict's vomit or preserve evidence at the scene meant samples could not be tested, which could have helped to identify what caused Benedict's reaction at an earlier stage.
Benedict's family criticised the report for focusing on what happened after the schoolboy collapsed, overlooking the "clear failings we believe happened at the school" before and during the incident.
The family said: "Highlighting those errors is what could genuinely help protect future children in school.
"The jury found serious issues: staff were not told about his allergic symptoms, established safety processes weren't followed, too many people were involved in preparing his care, and vital medication was given to him far too late to save his life.
"Instead, the spotlight has been placed on post-event actions, reflecting the chaotic way the investigation unfolded - an investigation that fixated on a biscuit, even though evidence showed very early on that it could not have been the cause.
"For the PFD to overlook the systemic failures that happened before and during the incident is a profound missed opportunity.
"If we truly want to prevent future deaths, the focus must be on the mistakes that should have kept our son safe and that they should not happen again."
Benedict's family is campaigning for Benedict's Law to be implemented across the country, requiring every school to have an allergy policy, allergy training and allergy pens.
In August, Benedict's sister Etta joined other children affected by allergies to stand in front of No 10 and knock on the door to hand over a petition calling for the law, which was signed by more than 13,000 people.