Inquest Finds School Allergy Procedures Not Fully Followed Before Pupil’s Death

A jury has concluded that key safety measures were not followed in the case of five-year-old Benedict Blythe, who died after an anaphylactic reaction to cow’s milk while attending Barnack Primary School in Stamford, Lincolnshire.

What Happened on the Day

On 1 December 2021, Benedict returned to school after a day off. During morning break, he ate a gingerbread biscuit brought from home. He then returned to the classroom, where oat milk was offered — but refused.

Shortly afterwards, he became unwell. Staff attempted to respond, but the jury heard there were delays in both recognising the symptoms and administering the adrenaline.

The milk provided that day had not been poured in the classroom as per the agreed protocol, but instead had been prepared in the staff room and brought in — a deviation from the allergy care plan.

Family and Legal Response

Benedict’s mother, Helen Blythe, gave evidence during the inquest and has since spoken out, saying her son’s death was “preventable” and the result of a “cascade of failures – individual, institutional and systemic.” She added; “Benedict died in a place where he should have been safe – his school. We’ve waited years for answers. There must be change. No more children should die at school because of an allergy.”

She is now calling for "Benedict’s Law" – legislation to ensure mandatory allergy management policies in all schools, including clear communication, training, and emergency procedures.

Jury's Findings

After six days of evidence at Peterborough Town Hall, the inquest jury found that:

Benedict died due to accidental exposure to cow’s milk;
Staff did not follow all of the agreed allergy management measures that had been carefully put in place with his parents;
There were delays in administering Benedict’s adrenaline pen once symptoms began;
There were missed opportunities to review previous incidents, including an earlier allergic reaction in October 2021 when Benedict was served pizza at school; and
Contributing factors included:
- A change in procedure for how his oat milk was handled that day
- Lack of awareness of his allergy care plan among teaching staff
- Late recognition of symptoms and a delay in emergency response
- Possible cross-contamination risks

girl eating cereal in white ceramic bowl on table

Benedict, who had multiple severe allergies - including to milk, eggs, nuts, and kiwi - collapsed at school in December 2021 after being accidentally exposed to cow’s milk protein. Despite efforts to save him, he was later pronounced dead at Peterborough City Hospital.

Key Lessons for Schools

This heartbreaking case serves as a powerful reminder of the critical importance of allergy safety in school settings.

Key takeaways for all schools:

Clear Allergy Action Plans

Ensure Individual Healthcare Plans (IHPs) and allergy action plans are in place, up to date, and shared with all relevant staff, including temporary or supply teachers.

Consistency in Procedure

Procedures around food preparation, storage, and serving must be followed exactly as agreed; and
Any deviation — even if well-meaning — introduces risk.

Emergency Response

All staff must be trained in recognising the early signs of anaphylaxis; and
Staff must know how and when to use an adrenaline auto-injector (AAI) and where it is stored.

Reflective Practice

Any prior incidents — even if non-fatal — should lead to a formal review of processes and staff training.

What Happens Next?

While the school involved has not commented publicly, the case has prompted national discussion on allergy policy in education. Campaigners and the family are now calling on the government to strengthen legal requirements around allergy management in schools.

If your school would like to review its allergy policy, training, or emergency procedures, consider:

Booking refresher training for all staff;
Reviewing your First Aid and Medical Conditions policy;
Checking expiry dates and accessibility of AAIs; and
Ensuring communication systems are in place for supply staff and lunchtime supervisors

HANDSAM RESOURCES

a young boy sitting at a table eating a chocolate donut