Coroner flags concerns over first aid training

Oliver Steeper died in September 2021 after choking at nursery

A baby who choked at nursery died as a result of misadventure, an inquest jury has concluded.

Oliver Steeper died six days after he choked at Jelly Beans Day Nursery, in Ashford, on 23 September 2021.

Coroner Katrina Hepburn told the jury at Oakwood House, Maidstone, that there was "no evidence which would show failures by nursery or its staff".

However, she will now make a Report to Prevent Future Deaths for the Department for Education as "it was apparent from evidence" that staff were "not able to put into place Resuscitation Council guidelines" in an emergency.

Oliver was eating pasta bolognese when he choked

Ms Hepburn said: "I am concerned that even staff with valid training, without having regular refresher training, they may not recall the finer particulars of first aid."

She also raised concerns about current early years guidelines, where only one staff member has to have a valid paediatric first aid certificate.

A pathologist's report had concluded that choking led to Oliver suffering a cardiac arrest and "unrecoverable neurological damage".

He had no underlying disease that predisposed him to a choking episode.

At the beginning of the inquest, Oliver’s mother, Zoe Steeper, said he had been eating pureed meals at home, and she'd been assured by nursery workers that solids could be blended before being fed to him.

Following the conclusion of the inquest, she said she believed her son’s death was “entirely preventable” and called for changes to the “loopholes” in the nursery system.

“We entrusted Jelly Beans nursery with our most prized possession - our beautiful baby boy,” she said.

“We feel he wasn’t ready for the type of meal he was given, and we maintain that we never gave the nursery permission to unilaterally make that decision.

“No parent should ever leave their child at nursery for them not to come home.”

Oliver’s mother, Zoe Steeper, said she believed her son’s death was “entirely preventable”

The jury also heard from Oliver's key worker at the nursery, Loetta Collins, who said she had not received training about the size the food should be served.

Ms Collins said she was “content” that the pieces of penne pasta bolognese she chopped were small enough.

Another member of nursery staff, Nazia Begum, told the inquest she had been feeding Oliver and three other children at the same time.

She said feeding this many children was "not usual".

The inquest heard how her first aid qualification was more than a year out of date.

Jelly Beans Day Nursery in Ashford is now closed

The jury previously heard from a resuscitation expert that the basic first aid Oliver was given by nursery staff was "poor".

He added: “It cannot be concluded that a higher standard of first aid care given to Oliver would have made a difference to the outcome.”

It was said while there was some good practice including firm back slaps and calling for an ambulance, Jelly Beans nursery manager Debbie Alcock was criticised for inserting her finger into Oliver's mouth when there was no obvious sight of food.

A consultant at the Evelina London Children's Hospital, where Oliver died, said more than half of his airway was constricted and a “significant amount of food debris” was found in his airways.

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