On 11 April last year radiographer Wendy Egan dropped off her five-month-old son Thomas at his nursery. Two hours later he was dead, his death caused in part by an acute allergic reaction. Now childcarers around the country are seeking to learn from the case and take steps to ensure that such a tragedy can never be repeated.
Thomas's parents and staff at Brownswood Nursery, Milton Keynes, knew of his milk allergy, but a breakdown in communication and procedures resulted in Thomas being fed a cereal containing milk products.
That morning, nursery nurse Crystal Norman hadn't spoken to Mrs Egan and instead asked Katie Moat (now Toon), an untrained support worker, if Thomas had had his breakfast. Ms Moat replied that he had had his milk, which Ms Norman took to mean that he had not had breakfast. Despite Thomas never usually having breakfast at the nursery, Ms Norman proceeded to prepare the cereal.
She added only water to the cereal, which was suitable for children aged four months and over; she assumed that cereals for babies that age would not contain milk; she failed to read the 'with milk protein' printed on the top of the packet and she failed to read the signs posted in the nursery saying that Thomas should be fed only breast milk, baby rice and pureed fruit and vegetables.
The inquest gave a verdict of accidental death contributed to by neglect. As a result, the Jigsaw chain, which owns the nursery, may face legal action by both Thomas's parents and Milton Keynes Council.
Following the inquest, Gordon Egan, Thomas's father, said, 'The tragic reality was that we believe some procedures may have existed, but they were inadequate and not being applied in practice.' The Anaphylaxis Campaign hopes that childcarers will avoid a knee-jerk reaction to the case by refusing to look after children with allergies.
Private nurseries can refuse to care for a child with an allergy, though the position of maintained schools is less clear. David Reading, director of the Anaphylaxis Campaign, says, 'Schools have been brought under the Disability Discrimination Act, which states that they cannot discriminate against a child on the grounds of disability, but whether this covers allergies hasn't been put to the test in the courts.' Small risk
He acknowledges that allergies in young children are on the rise - about one child in 50 has a potentially severe food allergy, and new allergies are emerging. But, he is keen to stress, 'The risk of a child dying from his or her food allergy would be one in 800,000 a year. Thomas's death is the only confirmed infant death from milk allergy in the UK in the last ten years.'
Significantly, he says, Thomas was still suffering the after-effects of bronchiolitis, which exacerbated the breathing problems caused by the cereal and was 'a crucial factor leading to his death'. He was also too young to be prescribed an adrenaline pen, which offers older children protection if they suffer an acute allergic reaction.
Mr Reading concludes, 'Parents or childcare staff can be assured that a robust management plan, covering allergen avoidance, medical procedures and staff training, will protect allergic children. This always has been our policy, and this is unchanged.' What is clear is that meeting the needs of children with allergies is now part of daily life in nurseries around the country. Every private nursery that spoke to Nursery World reported looking after children with allergies.
John Woodward, managing director of the Busy Bees chain of 24 nurseries, says, 'Every one of our nurseries have children with allergies, with differing degrees of severity.' At William House Day Nursery in Darlington, an 84-place nursery attended by almost 200 children a week, the list of allergies runs to 'nuts, tomatoes, raspberries, strawberries, bananas, eggs, soya and dairy products, semolina, paste spreads, hot dogs and Sunny Delight'.
Common features emerged in the policies and procedures of nurseries that spoke to Nursery World: they collect information about allergies when a child is registered; agree a care plan with the parents; include the care of allergic children in staff inductions; ban nuts completely from the premises; display lists of children's allergies in every room; use as much fresh food as possible (to avoid problems with poor labelling on packaged foods); operate a coded system of dishes when serving meals, and double-check dishes before serving them.
Unusually, William House employs a nurse, who administers any medication that a child may need. Owner Mary Boulton first employed a nurse over ten years ago, long before allergies had become an issue for childcarers. 'I always felt it was a good idea to employ a nurse,' she says.
Best practice
What is best practice in caring for children with allergies is now under the spotlight. Jigsaw has now overhauled its policies and procedures. The National Day Nurseries Association (NDNA) is planning to issue guidance to its members, and some nurseries are reviewing their procedures. What are the main messages?
* Undertake a risk assessment for each child and plan accordingly, says Mike McKechnie, chief executive of Jigsaw, which has now established a tiered response to children's allergies to ensure that staff can devote time to undertaking the most rigorous checks for those with the most acute needs.
This approach was adopted after their research showed that 700 of the 4,000 children on their registers had an 'intolerance, allergy or preference'. Of those, only 117 cases had a medical diagnosis and 52 were identified as potentially serious and possibly requiring hospitalisation.
With the 52 cases, Jigsaw has insisted that a treatment plan be provided by the child's doctors, and included in their procedures a system of triple-checking any food the child eats - cross-referencing ingredients to allergies; having parents sign off their child's menu every morning; and having staff again check the meal when it is served. In the rest of the 117 cases, procedures have been agreed with the parents, based on medical information passed directly or via the parent to the nursery.
In the 583 other cases, parents were twice asked to provide medical evidence of their children's allergy, but many did not do so or indicated it was in fact only a preference. In response, Jigsaw says it abides by parents' wishes and ensures the children are not given certain foods but does not apply the most rigorous triple-checks.
As an added precaution no child, with or without allergies, is given any food, liquid or medicine that they have not already had at home without any adverse reaction.
* Improve and update regularly the level of information from parents. In his summing up in the Thomas Egan case, the coroner noted that there was conflict over how much information Mrs Egan actually passed and should have passed to the nursery.
NDNA chief executive Rosemary Murphy says, 'We are suggesting that where there is a history of allergies, the parents should arrange some dialogue between the medical profession and the nursery.' * Provide staff with adequate information and training. Staff need to be made aware of the full range of possible allergic reactions, Mrs Murphy believes, as the word 'allergy' is a blanket term giving no real clue as to its potential severity in some instances.
Jigsaw has introduced a four-day first-aid course for its managers and deputies.
Mr Woodward advises running regular refresher courses and even 'tweaking' procedures so staff remain alert to what is expected of them.
* Make sure staff are aware of their individual responsibilities, advises Coombe Valley managing director Sue Ranson. 'Our culture is that each nursery nurse is in the end responsible morally, if not in law, for making sure that they have checked everything as thoroughly as possible,' she says.
* Be prepared for emergencies. 'You can't rely on eliminating all the potential sources of the allergen,' warns Mr McKechnie - a point well illustrated recently at a Jigsaw nursery when a child with a nut allergy had to have adrenaline administered after reacting to the smell of coconut shampoo on another child's head.
Mrs Murphy agrees. 'It's the unpredictability of allergies that you've got to watch out for. No matter how well prepared you are, there will always be reactions that you can't anticipate.' All the nurseries contacted by Nursery World plan to continue caring for children with allergies. Mr McKechnie, however, says that if there were ever another case like the Egan case, Jigsaw would review its policy. 'We'd have to evaluate whether we want our nursery nurses exposed to that level of risk and ask ourselves: Is it fair?'
Additional reporting by Alison Mercer
Further information
* The Anaphylaxis Campaign free information pack on allergies. To order a copy, phone 01252 542029. See also www.anaphylaxis.org.uk
* Supporting pupils with medical needs is available from DfES Publications, tel: 0845 6022260.
* 'In reaction' - a guide to setting up policies for children with allergies, Nursery World, 30 January 2003, p21.
