Report on boy's death was a 'missed opportunity'

The family of a five-year-old who died after an allergic reaction at school have criticised a report into his death.

An inquest jury found Benedict Blythe, from Stamford, Lincolnshire, died after accidental exposure to cow's milk protein at Barnack Primary School in December 2021.

In her Prevention of Future Deaths (PFD) report, coroner Elizabeth 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 identify what caused his reaction at an earlier stage.

However, Benedict's family said it was "devastating" that the report did not "address the clear failings we believed happened at the school".

Ms Gray, the area coroner for Cambridgeshire and Peterborough, asked the Royal College of Pathologists to revise its procedures around samples collected during post mortem examinations in cases of suspected anaphylactic reactions.

She also called on the police to ensure it collects evidence such as vomit in cases of this kind.

Benedict's family said the report had concentrated on "what happened after Benedict collapsed" rather than "the failures before and during the incident".

"For the PFD to overlook the systemic failures that happened before and during the incident is a profound missed opportunity," they said.

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

In July, an inquest jury looking into Benedict's death found that the school did not follow all the measures in place to prevent his death from a fatal anaphylactic reaction to cow's milk which he had been given accidentally.

It also found there were risks of contamination and delays in administering an adrenaline pen.

The report said initial investigations focused on Benedict having eaten a McVitie's biscuit that he brought in from home on the day he collapsed.

It later became clear the biscuit did not cause his anaphylactic reaction, but that he had probably been given cow's milk protein in his bottle during break time.

Benedict's family said: "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."

The family are campaigning for Benedict's Law to be implemented across the country, requiring every school to have an allergy policy, training and allergy pens.

The BBC has contacted Barnack Primary School for a comment.

In a statement, Cambridgeshire Police said: "Our thoughts, as always, are with Benedict's family in relation to this case.

"We've noted the findings of the report and its recommendation for us – and we will always look to discuss and review all relevant potential forensic opportunities together with our scenes of crime team."

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