“That care plans are not in place for all pupils that require them”
Dated 1 Sep 2017, from the coroner for Birmingham and Solihull. Sent to 4 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 27 Oct 2017. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated1 Sep 2017
- Deadline27 Oct 2017
- Published on judiciary.uk2 Oct 2017
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Caterlink | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 27 Oct 2017. A reply may have been sent and not yet published. |
| Birmingham City Council | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 27 Oct 2017. A reply may have been sent and not yet published. |
| Al Hijrah School | Response publishedPublished on judiciary.uk in October 2017. |
| Birmingham Community Healthcare NHS Foundation TrustNamed in the report as “Birmingham Community Healthcare NHS Trust” | Response publishedPublished on judiciary.uk in October 2017. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— 1. That care plans are not in place for all pupils that require them. Evidence was heard at the Inquest that the deceased's sister’s care plan is still inaccurate, despite this having been identified to the school. 2. That there are delays in issuing care plans. Care plans need to be issued quickly where a child has an allergy. 3. All issued care plans had not been provided to Caterlink by the school and communication between the school and Caterlink was not as effective as they could be. 4. Asan interim measure lanyards had been used to try and identify which food children were allergic to when buying their lunch. The Inquest heard how some lanyards were not accurate and lanyards themselves are not safe as they may be amended or worn by a different pupil. 5. Immediately following this tragic event, the Local Authority procured a report to look at the safety of food delivery in the school. That report identified a number of matters requiring attention which included identifying that the lanyard system that the school had introduced as an interim measure was not safe. This recommendation and others were not communicated to the school or anyone else, to enable them to make essential changes to processes to ensure the management of children with food allergies was adequate. | am therefore concerned that the local authority has no process in place to ensure that recommendations are immediately communicated to those affected by them so that practices can be changed and processes put in place to rectify the problem.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2017-0243
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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