An allergen at school and delayed administration of adrenaline probably contributed to the death of Benedict Blythe

Benedict, who was allergic to cow’s milk protein, had an allergic reaction while at Barnack Primary School, Stamford on Wednesday 1 December 2021 and died the same day at Peterborough City Hospital.

The jury concluded he died following an accidental exposure to an allergen, cow’s milk protein, causing fatal anaphylaxis. They said the probable source of the allergen that caused the fatal anaphylaxis was the ingestion of cow's milk protein, most probably from his own receptacle during break.

The jury’s conclusion was welcomed by Benedict’s family. It identified various factors that probably contributed to Benedict’s death, including delayed administration of his adrenaline pens, opportunities for cross contamination or mix up of milks due to control measures at the time, lessons hadn’t been learned from previous allergic reactions in school, and Benedict’s allergy plan was not shared with the staff responsible for his care.

Teachers, doctors, paramedics and representatives from the Department for Education, and snack-food company, Pladis, were among those who gave evidence at Peterborough Town Hall between Monday 30 June 2025 and Monday 7 July 2025. The inquest concluded on Wednesday 9 July 2025.

The inquest heard that there was an agreed process for serving Benedict with his alternative milk at school. It involved taking alternative milk from his named carton in the staff fridge where it was stored, pouring it into Benedict’s cup in the classroom and handing it straight to him.

However, on the day Benedict suffered his fatal allergic reaction, the milk was poured out in the staff room and then taken to the classroom where it was served to children, including Benedict.

Benedict began to feel unwell after break time, was sick and was taken to change his clothes by a first-aider. He asked for his inhaler, but because he has been sick, it was not given to him. After he was sick a second time, Benedict lost consciousness. His adrenaline was administered twice and CPR was attempted by staff before paramedics arrived and also administered adrenaline. Benedict was taken to hospital, where his death was recorded.

On the record of inquest, Benedict’s cause of death has been listed as food-induced anaphylaxis.

Speaking outside Peterborough Town Hall, his mother, Helen Blythe said that “Benedict’s life mattered. His death must matter too”.

Following campaigning work by The Benedict Blythe Foundation, on Wednesday 9 July 2025, permission was sought in the House of Commons to bring in a Schools (Allergy Safety) Bill, or Benedict’s Law.

Redditch MP, Chris Bloor asked that this bill require schools to maintain an allergy management policy, require schools to hold a supply of adrenaline auto-injectors for treating allergic reactions and anaphylaxis and to require allergy training for staff in schools.

Benedict’s family hope this will now be endorsed by the ministers.

Benedict’s family are represented by Michelle Victor and Angela Bruno from the food safety team at law firm, Leigh Day. Michelle Victor has said that there is both a moral and legal duty on the state to protect the safety and wellbeing of children in school with allergies.

Following the conclusion, Benedict’s mother, Helen Blythe read a statement outside court on behalf of his family and said:

“Three and a half years ago, we lost our son. Benedict died in a place where he should have been safe – his school.

“Since then, we’ve been left in silence—without answers, without accountability. It has taken years of painful waiting, legal processes, and relentless perseverance just to uncover the truth. And even now, the truth is devastating.

“There were critical failings from the very beginning. The investigation at the time was inadequate as the evidence needed to establish how and why he died was never obtained. Because of that, precious time was lost—and with it, opportunities to understand what happened to our son.

“Benedict’s death was preventable and was caused by a cascade of failures—individual, institutional, and systemic.

“Despite knowing Benedict had a serious allergy:

• No allergy plan was created by the school, and the clinicians who understood his condition were never consulted.
• There was no specific allergy policy in place when he started school.
• Staff directly responsible for his care were not privy to key information relating to his allergies including how they may manifest.
• They misunderstood the signs of an allergic reaction, believing all symptoms had to appear before they could administer adrenaline. The key message is if “in doubt” give adrenaline.
• The staff responsible for his care were not given the training or support to enable them to act decisively in an emergency situation when every second mattered.
• Ultimately, Benedict’s adrenaline pens were given too late to save his life.

“There is no legislation that exists to protect children with allergies. Schools are left to interpret patchy, vague guidance and to carry life-or-death responsibility alone. This is unforgivable.
Benedict was kind and curious, clever and gentle, full of love and full of promise. And now, in his name, we say:

“No more children should die at school because of an allergy.

“We demand change. We call on this government protect our children with Benedict’s Law, making it mandatory to have:

• An allergy policy in every school
• Staff allergy training including understanding allergies, how to manage them and identify signs of a reaction, and respond quickly in an emergency
• Spare adrenaline allergy pens in every school

“Proper oversight. Real accountability. Immediate action. We owe that to every child. Every parent who sends their child to school and trusts they’ll come home. Every child with allergy safe at school.

“Benedict’s life mattered. His death must matter too.”

Leigh Day partner, Michelle Victor said:

“Benedict’s parents have waited almost four years to obtain answers as to how their son came by his death in school; a place where he should have been safe.

“The painful nature of this wait has been compounded by failures from the outset to effectively investigate and preserve vital evidence that could and should have identified how Benedict came by his untimely death.

“Time for change is now. No parent should fear sending their child to school for them never to return. We support the Blythe Family’s call for Benedict’s Law, which seeks to standardise and mandate the protective measures in school including:

• Effective, annual allergy and anaphylaxis awareness and emergency response training for relevant school staff;
• Spare auto-immune injectors in every school; and
• A standardised mandatory allergy policy in every education setting.

“We know that tens of thousands of children in England are living with food allergies.

“All pupils deserve to go to school and return home safely.

“The state has a duty to protect the safety and wellbeing of children in school. Teachers deserve to feel supported in fulfilling that duty. One cannot be achieved without the other.

“This is not only a legal but a moral responsibility.”

Counsel for the family are Jeremy Hyam KC of 1 Crown Office Row and Turan Hursit of Old Square.