The story of a near-miss

This is the story of a near-miss. Two, in fact.  

My son was just two and a half when he suffered suspected anaphylaxis after his nursery mixed up his food with another child’s. And he was just three when they did it again, in a slightly different way.  Egg is innocuous to most, but to an unlucky few it’s potentially deadly. My son is one of those few.  

The reason we picked the nursery attached to the plush-looking independent school was because we thought, with the professional kitchen and hundreds of children, that they would be able to handle allergen management. They’d have handfuls or even dozens of kids in the school with allergies, surely. They’d have their catering ducks in a row.  

We were assured as much by the chef, and by the head teacher. We’d given them the forms and letters of diagnosis and the medication and the hospital’s action plans. Sure, we noticed a few slightly raised eyebrows from staff but as a parent of a kid with allergies, you get used to that. The sense that people think you’re over-worrying. You learn just to smile and carry on.  

They didn’t know they’d given him the wrong cake. He knew, of course. It was the wrong colour. He tried to tell them, but no-one listened. What did he know? He was only two years old. Silly little thing. But it was the wrong cake. He ate it, having been assured it was safe. And then two hours later he suffered suspected anaphylaxis. At his grandparent’s home, he suddenly fell into a deep and unrouse-able sleep. With no visible rash, and no known mistake, it was assumed that he was simply a poorly two year old, ready for an early night. Perhaps he was coming down with a virus. 

His grandparents eventually roused him, and by the time we, his parents, got to him he was doubled over in pain, complaining of intense stomach ache. And, by then, with a tell-tale hive rash on his face.   

“What did you have to eat at nursery?” I asked. “My teacher did give me cake with egg in it” he replied. “It was orange not brown”. (Vanilla, not chocolate).  

The next morning, the nursery teacher gasped as she realised. The storage of his safe cupcakes and those of another child – with different allergies – had been mixed up.  The school had removed them from the labelled Tupperware boxes we’d provided them in, and had stored his cakes and the other cakes in loose plastic bags side-by-side. At some stage, some cakes had fallen out of one bag and been stuffed back into the other.  He had been given a cake containing egg. 

An expert allergy nurse told us that he had “been lucky”. It was likely to have been an anaphylactic reaction, she said. And had anyone known, he should have been given adrenaline and seen by a paramedic.

Despite the severity of what had happened, at that stage we thought that the best thing we could do would be to work in partnership with the school to improve their allergy processes. He was happy there. He had friends. We didn’t want to pull him out unnecessarily.  

So we borrowed an allergen management policy from a competitor, and asked the school to adapt it for their own setting, and to then to formally adopt it into their practice. It took quite a bit of cajoling but we were eventually reassured that had happened. The policy was in place, they said. 

Except it wasn’t. It had never been sent to the governors for approval and it had never been added to their website as an official policy. No parents were notified of the new and improved allergen management processes.  The whole thing had been an exercise is placating two parents they saw as needlessly anxious. The school had learned nothing from the near-miss. 

That’s what we realised after the school made a similar mistake again.  

At the Christmas lunch, our son was again given cake containing egg. A volunteer from outside joined the team and was allowed to feed the kids. She had apparently been briefed on his allergies – he was to be given jelly not cake, but – amid the festive jollity and busyness – it had slipped her mind.  

The school realised more quickly that time, and phoned me. I instructed them to give him antihistamine. We rushed down to the school – furious and terrified in equal measure – and drove our three year old to A&E for observation, given the severity of his reaction the previous time.  When hearing the story, looking down at our toddler, the doctor’s professional façade evaporated and his horror was apparent. This time, however, the antihistamine worked and my son was fine. 

After this second error, the school’s inability to take allergen management safely was clear, we reported the incidents. The school was formally investigated by the local Trading Standards and was considered for criminal prosecution. Staff members were interviewed. In the end, Trading Standards decided to spare the school from criminal charges but instead issued them with a written warning. That remains on record should the school ever make another mistake. 

So, my son had a near-miss with a likely-anaphylactic reaction which wasn’t fatal. And the school had a near-miss with an investigation which dodged full prosecution. Still, I hope they’ll learn from the experience. It’s not an experience that we’ll ever forget.  

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