Coroner at inquest into the death of baby Oliver Steeper who died after choking at his nursery calls for tighter first aid regulations in early years childcare

The jury at Kent and Medway Coroner’s Court found Oliver died after inhaling food and choking as he was being fed by staff at Jelly Beans Day Nursery in Ashford, Kent on 23 September 2021.  

Oliver, known as Oli by his family, was treated by paramedics at the scene, and William Harvey Hospital, before being transferred to Paediatric Intensive Care Unit at Evelina Children’s Hospital in London. Medical procedures later discovered a significant amount of food debris within Oli’s lungs, some of which doctors were unable to remove. He was unable to survive his injuries and died at Evelina Hospital six days later.  

Returning a conclusion of misadventure, the jury ruled that Oli, who was only eating pureed and limited finger food at home, died from brain damage caused by a lack of oxygen after suffering a cardiac arrest as a result of the choking incident.  

Area Coroner Katrina Hepburn said she would issue a prevention of future of deaths report to the Department of Education on the following issues: 

Early years childcare providers only needing to have one member of staff with a valid paediatric first aid certificate, despite the fact they could be responsible for large numbers, in this case up to 80, children. 

Even staff with a valid paediatric first aid certificate were not able to put into place recommended guidelines and recommended regular refresher courses. 

She added, “It is apparent from evidence in this case that when confronted with an emergency situation of a choking child that staff, even those with a valid certificate in place, were not able to put into place the Resuscitation Council guidelines. For example, no chest thrusts, a mouth sweep was given against the guidelines, staff were unsure of the strength of backslaps. I am concerned that even staff with valid training, who had it up to 3 years earlier, without regular refresher may not recall the finer particulars to ensure effective first aid is given.” 

The 7-day hearing at Kent and Medway Coroner’s Court in Maidstone heard that a post-mortem examination by pathologist Dr Charlotte Randall found Oli “suffered unrecoverable neurological damage” and concluded that choking had led to cardiac arrest. The pathologist confirmed that “fragments of food were removed from airways”. The jury was told Oliver had no underlying disease that predisposed him to a choking episode. 

Before the incident, Oli’s mother Zoe Steeper described to the inquest visiting the nursery on several occasions and discussing his feeding requirements with staff, telling them Oli was eating only pureed meals and limited finger food at home. At the time Oli only had two partially grown bottom teeth and was unable to properly chew solid food. Zoe recalled being told by staff this was ok because they had a blender to make pureed food on site.  

Oli attended Jelly Beans on Thursday 23 September 2021. At around 1130 that day, Zoe received a call from the nursery saying Oli had had an accident whilst eating, had choked and was being treated by paramedics. Zoe arrived at the nursery a short time later to find paramedics running to the ambulance performing CPR on Oli. Oli was then taken to William Harvey Hospital by ambulance accompanied by his mother. On arrival at the hospital, she heard from the paramedics that Oli had apparently choked on some pasta which he had been fed at the nursery. 

Doctors at the hospital were able to restore Oli’s heartbeat but advised he needed to be transferred to the Evelina Children’s Hospital in London for specialist care. Sadly, his condition worsened and on arrival at the Evelina Zoe and Lewis were informed by doctors that Oli would not survive. Over the next few days tests confirmed that Oli’s brain was irreparably damaged. Oli passed away on Wednesday 29 September 2021.   

Oliver’s parents Lewis and Zoe Steeper are represented Leigh Day partner Jill Paterson. The family have instructed barristers Helena Spector and Janine Wolstenholme of Park Square Barristers.   

Zoe Steeper said: 

“On 23 September, I dropped Oli off at nursery. He never came home again.   

“We have heard evidence in court that the nursery fed our 9-month-old baby chopped penne pasta bolognese. He choked and died. A significant amount of food debris was found blocking his lungs.    

“In Court, we were shocked to hear various witnesses give evidence about the scene of total chaos that unfolded that day in front of many other little children. Oli was only 9 months old.  He was just a little baby. Why did this happen? We believe that Oli’s death was entirely preventable. 

“Oli was still on milk, and we had started to move him on to pureed and appropriate finger foods at home, always under our watchful eyes.  He had only just started teething, and only had 2 little bottom teeth that had started to grow.  We feel he wasn’t ready for the type of meal he was given, and we maintain that we never gave the nursery permission to unilaterally make that decision.   

“We entrusted Jelly Beans nursery with our most prized possession - our beautiful baby boy.  We were assured that they would look after him properly. No parent should ever leave their child at nursery for them not to come home. 

“Hundreds of thousands of children are looked after by nurseries every day in the UK.  It generates an estimated income of £4.7 billion pounds each year.  It is big business.  Oli’s case has shone a light on what we feel are loopholes in the way that nurseries are allowed to care for young children and babies.  We have waited more than two and half years for Oli’s voice to be heard. We now want to see meaningful change to ensure no other family has to go through the heartbreak of losing a baby in this way whilst in the care of others.” 

Leigh Day partner Jill Paterson said: 

“Oli’s death was an unimaginable tragedy and one that no parent should have to endure. Despite the devastating grief our clients have had to go through, they are fully committed to ensuring that important lessons are learned from this terrible incident and that nurseries and other early childhood settings become safer places in future.  

“Urgent action must be taken by all those involved in the Early Years Sector, including regulators, legislators and childcare providers, to ensure that this appalling tragedy that cost the life of a baby boy never happens again.”