Following the verdict, the baby's father, Gordon Egan, said he and his wife Wendy would be pursuing further discussions with the Crown Prosecution Service regarding possible corporate manslaughter charges. He said that when Thomas started at the nursery at Browns Wood, Milton Keynes, they had given specific details of his allergy to cow's milk.
Mr Egan added, 'We were assured by staff at Jigsaw Nursery that appropriate procedures and practices were in place to ensure that our instructions would be followed. The tragic reality was that we believe some procedures may have existed, but they were inadequate and not being applied in practice.'
Mike McKechnie, Jigsaw chief executive, said, 'From the outset, we have always accepted that a mistake was made, but the chance that a mistake of this kind could have such tragic consequences was less than one in a million - as the coroner's expert medical witnesses explained during the inquest.
Philip Winsor, chief environmental health officer for Milton Keynes Council, said his department was considering taking further action against the nursery for breaches of the Health and Safety at Work Act and its legal team was examining the case.
At the time of his death, Thomas' airways were restricted following a bout of bronchiolitis. Dr Katumba, who saw Thomas at Milton Keynes General Hospital on 13 February 2002 for a routine check-up, told the inquest he had diagnosed Thomas as having 'hyperactive airways disease following bronchiolitis'.
In his summing-up, Rodney Corner, the coroner, said, 'Thomas should not have died as a result of the milk allergy, but because the airways had been damaged, once the anaphylaxis began to take hold, it was that much more difficult for him.'
Thomas did not usually have breakfast at the nursery, but a comment made by Mrs Egan when she handed him over on 11 April was misinterpreted by a new member of staff and he was fed the cereal by early years practitioner Crystal Norman as a result. Ms Norman did not realise that the cereal contained milk protein, although this was clearly labelled. She said, 'I did not expect to find milk in a cereal for a four-month old baby.'
During the course of the inquest, it emerged that the nursery staff believed that if Thomas was fed cow's milk it would make him sick. They said they did not know that when Thomas had been exposed to milk protein in formula feed he had developed a rash and his tongue had swollen up.
