‘A cascade of failures': How a five-year-old UK boy's fatal milk allergy reaction exposed alarming lapses in school's safety protocols; symptoms to watch out for

Indian Express

11-07-2025

A tragic case from the UK has reignited conversations around food allergy protocols in schools across the world. Five-year-old Benedict Blythe, who had known allergies to milk, eggs, kiwi and nuts, died on December 21, 2021 after what his mother called 'a cascade of failures,' including exposure to cow's milk and a delay in receiving emergency treatment.
After a thorough investigation, a UK inquest determined the probable cause of death was 'the ingestion of cow's milk protein, most probably from his own receptacle during break time,' suggesting that Benedict may have been mistakenly served another child's milk, according to the BBC.
Despite established protocols between the family and Benedict's school to store his oat milk separately in the staff fridge, the school also stored another student's lactose-free milk in the same fridge. On the day of the incident, the milk was poured in the staff room instead of the classroom. Benedict became ill and vomited, 'the first sign' of his allergic reaction, according to his mother, but his EpiPen was administered too late.
Dr Shuaib Nasser, an allergy specialist who had treated him, said, 'In hindsight, yes, it was administered too late,' per the BBC. Benedict collapsed shortly after, and though CPR was attempted, he died less than two hours later at a nearby hospital due to food-induced anaphylaxis.
Dr Jagadish Hiremath, public health intellectual, tells indianexpress.com, 'Managing children with severe food allergies requires a well-coordinated and proactive approach. The first step is early diagnosis and clear communication. Once a child is diagnosed with a serious allergy, parents must provide schools with a comprehensive medical action plan that outlines the allergen, symptoms of a reaction, emergency contacts, and treatment steps.'
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Schools must maintain up-to-date health records and ensure this information is accessible to all relevant staff, especially teachers, cafeteria personnel, and transport staff. There should be strict policies in place to avoid accidental exposure. Dr Hiremath adds that education is equally vital. 'Teachers and caregivers should be trained to recognise early signs of an allergic reaction and know exactly what steps to take. Simple protocols like handwashing before and after meals, not sharing food, and reading ingredient labels can significantly reduce risk.'
Dr Hiremath informs, 'Epinephrine must be administered immediately at the first signs of anaphylaxis or a severe allergic reaction that can occur immediately after getting exposed to an allergen. Delayed use of an epinephrine auto-injector is one of the most common reasons for fatal outcomes. It is most effective when given within minutes of symptom onset. Every minute counts.'
Symptoms that should never be ignored include difficulty breathing, wheezing, sudden drop in blood pressure, swelling of the lips or face, hives, and persistent vomiting. In children, even sudden behavioral changes like confusion, lethargy, or complaints of a 'funny feeling' in the mouth or throat can be early warning signs.
'Importantly, once epinephrine is administered, emergency services must be contacted immediately,' he stresses.
'Yes, schools in India should absolutely be required to stock spare epinephrine auto-injectors and train their staff in allergy response,' stresses Dr Hiremath. 'This should be seen as an essential part of a school's health and safety preparedness, just like fire drills or first aid.'
Implementation can begin with clear national or state-level policy guidelines on allergy management in educational institutions. Schools should designate trained staff members responsible for maintaining emergency allergy kits and conducting refresher training. Basic training on allergy symptoms, use of EpiPens, and emergency protocols can be included in teacher orientation and annual safety reviews.
Collaboration with pediatricians, allergists, and public health bodies can help schools develop practical and medically accurate response plans.
DISCLAIMER: This article is based on information from the public domain and/or the experts we spoke to. Always consult your health practitioner before starting any routine.