On behalf of the parents of Nasar Ahmed
“The Inquest into the tragic death of our 14 year old and first born son, Nasar Ahmed, has now finished. It has been extremely difficult to sit through the evidence of our son’s last conscious minutes. To hear about his fear and panic, and his struggle to survive will haunt us forever.
We are deeply saddened to now know of the missed opportunities to save Nasar’s life. We have heard about individual errors in preparing his Independent Health Care Plan, of review and awareness systems that were ineffective, and that staff were not adequately trained. 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 Epi-Pen 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. 1 in 11 children suffer from asthma nationwide. Every 20 minutes a child is hospitalised due to asthma. 78% of people who die of anaphylaxis were diagnosed with asthma. Schools in London and across the country need to urgently review the care of pupils with asthma and allergies. They need to make sure that their staff know what to do in an emergency and have the equipment to save lives. We are grateful to all those in our local community who have supported us and prayed for us.”
The Coroner gave an extensive narrative verdict which raised significant concerns about the systems in place for pupils with emergency medical needs and the actions taken in the 10 minutes between Nasar first alerting staff to the arrival of paramedics. The Coroner listed eight factors contributing to the situation that led to the loss of Nasar’s life. Her conclusion was that had appropriate steps been taken that it was possible that Nasar’s life could have been saved.
The Coroner has sent five Preventing Future Death reports to a range of public bodies, including Bow School, Bart’s NHS Trust and the Chief Medical Officer. The Coroner asked for urgent consideration to be given to the passionate plea made by the Paediatric Respiratory Consultant that Epi-Pens should be available in all public places in the same way that Defibrillators are currently.