A five-year-old boy who suffered a fatal allergic reaction at school died after accidentally ingesting cow’s milk protein — most likely from his own bottle, an inquest jury has concluded.
Benedict Blythe, a reception student at Barnack Primary School in Stamford, Lincolnshire, died on 1 December 2021 after going into cardiac arrest. He had a severe allergy to milk, as well as to eggs and certain nuts, and was also asthmatic.
The jury at Peterborough Town Hall heard Benedict vomited twice before collapsing. On Wednesday, the jury foreperson said:
“We deem the probable source of the allergen that caused the fatal anaphylaxis is the ingestion of cow’s milk protein, most probably from his own receptacle during break time.”
Benedict’s mother, Helen Blythe, speaking after the hearing, said:
“Benedict died in a place where he should have been safe – his school.”
“Benedict’s death was preventable and was caused by a cascade of failures – individual, institutional, and systemic.”
Jury identifies multiple failings
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Jurors ruled the cause of death as “accidental exposure to an allergen, cow’s milk protein, causing fatal anaphylaxis.” They cited several contributing factors:
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A delay in administering Benedict’s adrenaline
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Possible cross-contamination or confusion between milk cartons
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The failure to share his allergy plan with staff
They also pointed to his recent illness, the effects of exercise, his uncontrolled asthma, and a missed opportunity to learn from a prior allergic reaction he had in October after eating pizza at school.
Despite staying home the day before due to illness, Benedict returned to school in good health on the morning of his death. That day, he ate a McVitie’s gingerbread biscuit during break time — a snack he’d previously tolerated — and refused oat milk poured by his teacher.
Tests found no traces of cow’s milk protein in the biscuit. Benedict had also eaten dairy-free chocolate from an advent calendar and his usual cereal with oat milk for breakfast.
Area Coroner Elizabeth Gray instructed the jury not to link the allergic reaction to the biscuit, chocolate, or breakfast based on the evidence.
Dr. Shuaib Nasser, a consultant in asthma and allergy, told the inquest that a small amount of cow’s milk likely triggered the fatal reaction. He noted that Benedict’s milk allergy was severe and life-threatening, while his egg allergy was considered mild.
Delayed adrenaline and protocol breaches
The inquest revealed that a teaching assistant administered Benedict’s adrenaline auto-injector (AAI) twice before CPR and a defibrillator were used. He later died at Peterborough City Hospital.
Benedict’s oat milk, provided by his parents, was stored in a separate fridge in the staff room — alongside a carton of lactose-free milk intended for another student. His teacher, Jenny Brass, testified that she would not have confused the two, as lactose-free milk still contains dairy allergens.
However, the jury found the school’s usual routine for handling Benedict’s milk was not followed that day. His milk was poured in the staff room, not the classroom, and handed directly to him — breaking standard procedure.
Helen Blythe told the jury that the school had received a management plan for Benedict’s allergies, and vomiting was always his first symptom.
Remembering Benedict
Benedict had been described as “extremely bright” and a member of Mensa by age four. He loved school and was said to be thriving in his first three months there.
In his memory, the Benedict Blythe Foundation was established and, alongside The Allergy Team and the Independent Schools’ Bursars Association (ISBA), launched the schools allergy code last year — a guide to keeping pupils with allergies safe.
Speaking outside Peterborough Town Hall, Helen Blythe urged lawmakers to act:
“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.”
“No more children should die at school because of an allergy.
We demand change. We call on this government to protect our children with Benedict’s Law:
– Mandatory allergy policies in every school
– Staff training on identifying and managing allergies
– Spare adrenaline pens on-site
– Real accountability and immediate action.
We owe that to every child.”
