The parents of a teenager who died after suffering an allergic reaction to his school dinner have accused staff of failing their duty of care.
Nasar Ahmed was in an exclusion room with other pupils at Bow School in east London when he became unwell on November 10 last year.
His inquest heard that the 14-year-old, who had a history of severe asthma and food allergies, suffered a reaction to milk in his tandoori chicken lunch and went into anaphylactic shock.
But staff at the school failed to administer his EpiPen, which may have saved his life, the court was told. He died four days later in the Royal London Hospital.
Coroner Mary Hassell on Friday returned a narrative conclusion, saying: “The staff saw Nasar’s EpiPen and considered using it, but did not.
“If the EpiPen had been used promptly and Nasar had been administered adrenaline, there is a possibility but not a probability that this would have changed the outcome.”
Speaking outside the hearing at Poplar Coroner’s Court, Nasar’s mother Ferdousi Zaman told reporters: “If he has anaphylaxis I give him his EpiPen. They are first-aiders, they are more knowledgeable than me.
“They have failed their duty of care.”
Ms Hassell said she would be writing five Prevention of Future Death (PFD) reports, including to the school, his GP, Barts Health NHS Trust and the London Ambulance Service, whose paramedic told staff over the phone not to give Nasar adrenaline before they arrived.
Outlining her PFD to the ambulance service, she said: "The paramedic said don't give the EpiPen because there were no classic symptoms of anaphylaxis. The reality of giving a dose of adrenaline is that it is unlikely to do any significant harm, whereas the potential good of giving an EpiPen is lifesaving."
The coroner is also sending a PFD report to the Chief Medical Officer for England, asking whether EpiPens should be widely provided alongside defibrillators in public places.
Nasar was in the internal exclusion room (IER) at the school when he complained of breathing problems at 2.21pm on November 10.
The inquest heard that Nasar's asthma had been inaccurately listed by the school nurse in his care plan as "mild to moderate" rather than "severe" and did not mention an EpiPen or using adrenaline to tackle his allergies.
In her determination, the coroner said: "Staff at the school were encouraged to familiarise themselves with pupils' care plans but often did not unless there was a school excursion.
"Even the deputy head teacher, who had in the past taught Nasar, did not know about Nasar's food allergies or the fact he had a care plan and allergy action plan when he made the decision to place Nasar in the IER.
"Knowledge of the care plan would not have changed the decision... but the lack of familiarity of the IER supervisor and nearby members of staff with Nasar's allergy action plan and medication box used up time in an extremely time critical situation."
In a statement, Bow School's executive headteacher, Cath Smith, said: "We are all deeply saddened about this tragic incident and continue to offer our heartfelt sympathies to Nasar's family.
"The safety of those in our care is, of course, our overriding concern, and following Nasar's death we rigorously reviewed all of our safety procedures and are providing more training for staff across the board.
"We will now consider the advice from the coroner very carefully to see what further action we should take."
Year Nine pupil Nasar had asthma, severe eczema and a host of allergies, including to milk, fish, nuts, wheat, some meats, apples and oranges.
The inquest heard that a school cook told headteacher Daniel Lye that Nasar had eaten a tandoori chicken lunch containing milk at 12.20pm, about two hours before he collapsed. Nasar died from a brain injury brought on by the allergic reaction.
Staff who fought to save him had access to an inhaler and EpiPen from Nasar's personal medical box for five minutes before paramedics arrived, but were unsure whether to use them.
The inquest previously heard first aider Cherie Hyde and PE teacher Gemma Anderson were called to help Nasar after he began struggling to breathe during the detention period.
He called for his inhaler before collapsing, turning blue and foaming at the mouth.
Giving evidence at the inquest last week, Dr Chinedu Nwokoro, a consultant and clinical academic in paediatric respiratory medicine at Barts Health NHS Trust, called for a change to advice over the use of adrenaline injectors such as EpiPens.
He said: "If (a patient) has got respiratory compromise, give it; if (they) lose consciousness, give it; if there is any doubt, give it. It's not wrong."
Mrs Zaman said her son had been a "jolly" boy with a lot of friends, who had dreams of being a politician when he grew up.
She said: "His classmates, they are still sitting and waiting, they are thinking Nasar is coming back, maybe Nasar is coming back.
"They are sitting there in front of my balcony looking and thinking about him."
In a statement read by their solicitor Lochlinn Parker, the family added that they were "deeply saddened to now know of the missed opportunities to save Nasar's life".
"We strongly believe that if Nasar's care plan had been completed correctly, if staff had been aware of the care plan and if it had been followed properly, including administering an EpiPen as soon as possible, that Nasar would be alive today.
"Following our painful loss of Nasar we hope that important lessons about the care of children suffering from asthma will be learnt and other lives saved."