What We Learned from the Karanbir Cheema Inquest

Karan, as Karanbir Cheema — a 13 year-old boy attending the William Perkin Church of England School in West London — was known, died in the hospital in July 2017, ten days after suffering a severe anaphylactic reaction. The inquest into his death took place at Poplar Coroner’s Court last week.

Testimony confirms that on June 28, 2017, Karan was “pranked” by a schoolmate who “flicked” a piece of cheese at him.

When asked why by an attorney representing Karan’s family, the boy said: “I did not know to be honest … it was immature behaviour.”

He added: “I did not mean any harm towards him. I did not do it with bad intent. I didn’t mean to hurt him and obviously I feel bad now. I am sorry for what I did.”

Lucjan Santos, a science teacher at the school, reported what happened next:

“[Karan] said: ‘He put some cheese down my collar for no reason,’ and then he pointed towards the back of his neck,” Santos told the court. The teacher said he told Karan that that was not a nice thing to do, at which point the teenager said: “And I’ve got a cheese allergy.”

Santos sent Karan to the school’s welfare officer to fill out an incident report. He testified that at that point he “appeared fine and spoke calmly”.

Bonny Campbell, a school administrator with first aid training, testified that Karan arrived calmly at the welfare office, but became increasingly panicked, and began “leaning over the sink, gasping for air, still scratching his neck”.

She reported that blood was seeping through Karan’s shirt on his neck where he was scratching. “He pulled his shirt off, he was very itchy and couldn’t breathe,” she said. “He had scratch marks on his neck and his stomach, he was screaming.” She said that at one point he was shouting: “I’m going to die.”

The staff administered Karan’s inhaler and gave him an over-the-counter allergy medication. When his condition deteriorated, they administered an EpiPen which had expired 11 months prior. Campbell reported that it appeared to have no impact as he went “quite grey”, limp, and his eyes glazed over.

When asked by the coroner why a second EpiPen was not administered, Campbell testified that she was taught to wait 10 minutes before administering another dose during her first aid training, and that the emergency operator did not advise her to do so. She also stated that Karan had only a single EpiPen at the school and that they would not have administered another student’s EpiPen.

Paramedics testified that they were told on the phone that this was “just an allergic reaction”. but when they arrived, Karan was covered in hives, gasping for air. Shortly after their arrival, he stopped breathing.

The first paramedics on the scene performed CPR, administered more epinephrine, and used a defibrillator as they waited for support to arrive.

Karan was rushed to Great Ormond Street Hospital in critical condition. Ten days later on July 9, he was removed from life support.

Speaking on a local TV show, Rina Cheema, Karan’s mother, described the ordeal this way:

We didn’t want to switch it off – it wasn’t fair on his little body to go through this.

He smiled when the machine was turned off, they took him into another room and we said our last goodbyes before he was taken down and he had a smile on his face.

You’re always praying for the last minute miracle. His brothers and sisters and his uncles were all there beside him.

Allergist Dr Adam Fox testified that severe reactions from skin contact were “very, very uncommon” and he was “not aware of any fatal cases”. “If it was skin contact alone that caused, in this case fatal, anaphylaxis, I believe that to be unprecedented,” he said.

Senior coroner Dr Mary Hassell, recording a narrative into the record, stated that: “Karanbir’s school did not have an effective system for educating its pupils in the dangers of allergies.”

She added that the school’s healthcare provision was inadequate.

Ms Cheema told the Daily Mail:

My world has ended. He was my only son.

The whole family, his grandad, his brothers and sisters, his uncles and aunts all love him. He was the star of the show.

I think it will help a lot of children out there if whatever happened to our son the schools, all the institutions, the hospitals, the paramedics were made aware of how serious allergies are.

His school had not done enough to save our son, that says it all.

Our hearts go out to the Cheema family who were forced to relive the horror of Karan’s passing over the course of the inquest. We wish them solace in the coming days and that they take some comfort in the knowledge that their efforts to bring attention to the tragedy will lead to substantial changes to prevent other such tragedies from occurring in the future.

Myriad failings came together leading to Karan’s death. Here are a few glaring issues arising from testimony at the inquest:

• We know that Karan was first given his inhaler and an antihistamine, then — finally when his symptoms worsened — his EpiPen. It is unknown whether earlier administration of epinephrine would have saved Karan’s life, but we do know that the sooner epinephrine is administered when anaphylaxis is suspected, the better the outcome.

• We also know the first dose of epinephrine may not be sufficient to halt the progression of anaphylaxis. Individuals diagnosed with a severe food allergy should have at least two epinephrine auto-injectors on-hand at all times, and the medication must be kept up-to-date. Here is a recommendation from the American Association of Pediatrics on when to administer a subsequent dose of epinephrine:

  If the response to the first epinephrine injection is inadequate, it can be repeated once or twice at 5- to 15-minute intervals. From 6% to 19% of pediatric patients treated with a first epinephrine injection in anaphylaxis require a second dose. 29–31 A third dose is needed infrequently. Subsequent doses are typically given by a health care professional along with other interventions.

• There was no sense of urgency when Karan’s exposure was reported, as staff dismissed his early lack of symptoms as meaning nothing was wrong. Staff must be educated on proper emergency procedures that must be followed when exposure to known allergies presents itself in a school setting

• Finally, this tragedy was initiated by a prank perpetrated on Karan by a schoolmate, who we presume did not understand the grave danger he was putting Karan in. Schools must adopt training for students educating them not only on the dangers of food allergies, but how identify and respond to the symptoms of anaphylaxis.

Our hope is that Karan’s legacy will be for parents, school administrators, and students to learn to take food allergies with the seriousness and urgency of other life-threatening conditions.