The death of a boy after a severe allergic reaction at school is being investigated by the Health and Safety Executive, the BBC has learned. At the inquest, the coroner called the school's emergency response to Karanbir Cheema's anaphylaxis "inadequate".
Leading allergy specialist Dr Adam Fox says every school in England should have to hold emergency adrenaline pens. The Department for Education says it has changed the regulations to allow schools to buy them.
Karanbir's mother, Rina Cheema, wants people to see the photograph of her son in intensive care - so they understand an allergy can kill. She has lost her only child as a result of an extreme reaction as rare as it is devastating.
Karanbir suffered an anaphylactic reaction after cheese was flicked at him by another pupil at break time at his school in Greenford, West London. His mother describes herself as living in a black hole of depression because of the loss.
When the incident happened, in 2017, Karanbir went straight to the school office, where he was given his asthma inhaler and an antihistamine - but he continued to deteriorate.
After 10 minutes, his adrenaline pen was used by staff - but it was out of date and the second back-up pen was not in place.
An ambulance was called - but as paramedics arrived at Karanbir's side, half an hour after he had alerted staff, he went into cardiac arrest. The oxygen loss he suffered during the reaction was devastating - and he died 11 days later in hospital.
Rina now wants all schools to educate pupils and staff about the risks and how to deal with them. Within months of Karanbir's death, the law was changed to allow schools to buy emergency adrenaline pens. They cost about £50 to £70 each and can be used where there is no alternative available or no pen has been prescribed.
Life-threatening reactions are extremely rare but they are also hard to predict. About 5% of children in the UK have an allergy.
Adverse reactions to food are the most common. And just because a child has never had a severe reaction, that does not mean it might not happen in the future, particularly if they have poorly controlled asthma.
Dr Fox is alarmed by the patchy understanding of allergies in some schools.
Geoff Barton, General Secretary of the Association of School and College Leaders, says while schools are not required to hold spare devices, they are conscious that awareness and management of allergies is crucial. Their priority would be to ensure that children with severe allergies are supported and staff are trained in how to respond to the signs and symptoms of anaphylaxis, he says.
