Measures not followed before boy died, says jury

Benedict Blythe died after having an anaphylactic reaction to cow's milk at Barnack Primary School in Stamford, Lincolnshire

An inquest jury has found a primary school did not follow all the measures in place to prevent the death of a five-year old boy from a fatal anaphylactic reaction to cow's milk.

Benedict Blythe, from Stamford, Lincolnshire, vomited twice before collapsing at Barnack Primary School in December 2021. He was pronounced dead in hospital a short while later.

Jurors at the inquest into his death at Peterborough Town Hall concluded he had died after an accidental exposure to an allergen - cow's milk protein.

Calling for a new law to ensure schools have adequate allergy plans for children, Benedict's mother, Helen Blythe, said her son's death was "preventable and caused by a cascade of failures".

A Department for Education spokesperson said: "What happened to Benedict was a tragedy for his family and deeply affected all those involved on the day that he died.

"The Department for Education was represented at the inquest, and will consider the jury's conclusions carefully."

The school has been approached for comment.

Following six days of hearing evidence, jurors also found there were delays in administering an adrenalin pen by staff.

Benedict had asthma and a number of allergies including eggs, nuts, kiwi fruit and milk.

His parents worked with the school to put together a "number of preventative measures for Benedict", which included a personal allergy action plan and a specific process for storing, preparing and supplying oat milk to the pupil.

This involved storing the milk, which was labelled with the child's name, in the staff fridge and pouring it into Benedict's cup in the classroom before handing it directly to him.

However, on the day of his death that process was not followed because his milk had been poured in the staff room and then taken to him in the classroom.

The foreperson of the jury told the court: "We deem the probable source of the allergen that caused the fatal anaphylaxis is the ingestion of cow's milk protein, most probably from his own receptacle during break time."

Jurors also found there were missed opportunities to review "lessons learned" from a previous incident, in which Benedict was served pizza for lunch at the school in October 2021, which resulted in him being sick.

Among other factors that probably caused Benedict's death included "opportunities for cross-contamination or mix-up of milk, his allergy plan not being shared and distributed to teaching staff, and a late identification of his symptoms and treatment", the jury said.

Benedict was pronounced dead in hospital a short while after collapsing at school, an inquest into his death heard

Speaking after the conclusion of the inquest, Mrs Blythe said: "Three and a half years ago, we lost our son. Benedict died in a place where he should have been safe – his school.

"Since then, we've been left in silence - without answers, without accountability. It has taken years of painful waiting, legal processes and relentless perseverance just to uncover the truth. And even now, the truth is devastating.

"There were critical failings from the very beginning. The investigation at the time was inadequate as the evidence needed to establish how and why he died was never obtained. Because of that, precious time was lost - and with it, opportunities to understand what happened to our son.

"Benedict's death was preventable and was caused by a cascade of failures -individual, institutional and systemic."

The inquest previously heard milk was Benedict's only allergy that could have caused a potentially fatal reaction

Area coroner Elizabeth Gray was previously told the five-year-old was pronounced dead at 12:57 in Peterborough City Hospital and died due to food-induced anaphylaxis.

Jurors previously heard Benedict had been kept off school on 30 November after being sick the night before.

He went back on 1 December after Mrs Blythe, who gave evidence last week, said he "was fine and didn't appear to be unwell".

That day, while outside with other children during morning break, Benedict ate a gingerbread biscuit he had taken with him from home, the inquest had heard.

He then returned to the classroom, where he was offered oat milk but was said to have refused it.

He fell ill shortly after that before his death.

Speaking outside court earlier, Mrs Blythe said: "No more children should die at school because of an allergy.

"We demand change."

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