A five-year-old boy who died after an allergic reaction was accidentally exposed to cow’s milk protein – probably from his own bottle, an inquest jury has concluded.

Benedict Blythe was a reception pupil at Barnack Primary School in Stamford, Lincolnshire and died in hospital from food-induced anaphylaxis on December 1, 2021 after he vomited twice before going into cardiac arrest.

The court heard that Benedict, who joined high-IQ society Mensa aged four, was asthmatic and allergic to milk, eggs and some nuts.

The foreperson of the jury at Peterborough Town Hall said today: ‘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 mum Helen Blythe said after the inquest: ‘Three and a half years ago, we lost our son. 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.’

The delayed administration of his adrenaline, opportunities for cross-contamination or mix up of milk, and that his allergy plan was not shared with teaching staff were all factors that the jury found ‘probably caused’ his death.

A conclusion of ‘accidental exposure to an allergen, cow’s milk protein, causing fatal anaphylaxis’ was recorded by jurors.

Other factors included his recent illness, exercise, his uncontrolled asthma, and a ‘missed opportunity’ to review ‘lessons learned’ after he had an allergic reaction to pizza at school in the October before his death.

He was kept home from school the day before he died because he had been unwell and vomited.

The jury heard how he woke up ‘in good health’ the next morning before school.

The eight-day inquest heard that he ate a McVitie’s gingerbread biscuit during break time that morning, which he had eaten on previous occasions, and refused to drink a bottle of oat milk poured by his teacher.

A sample of the biscuit was independently tested for cow’s milk proteins, but traces were not detectable, the jury heard.

Benedict also ate dairy-free chocolate before he went to school, which his parents had put into an advent calendar, and his usual breakfast cereal with oat milk.

Elizabeth Gray, Area coroner for Cambridgeshire and Peterborough, told the jury they ‘may not record’ that the allergic reaction was a response to the biscuit, the chocolate, or his breakfast, based on the evidence heard.

Dr Shuaib Nasser, a consultant in asthma and allergy, said that a ‘small amount’ of cow’s milk most likely caused the fatal anaphylactic reaction.

This is because Benedict had a ‘life-threatening’ milk allergy – while his egg allergy was ‘mild’.

The inquest heard Benedict’s adrenaline auto-injector (AAI) was administered twice by a teaching assistant, before CPR and a defibrillator were attempted but he died later that day at Peterborough City Hospital.

Benedict’s oat milk, given to the school by his parents, was kept in a separate fridge in the staff room along with a carton of lactose-free milk for another child in his class.

Jenny Brass, a class teacher, told the inquest she would not have confused Benedict’s oat milk with the lactose-free milk, which he could not drink because it contained dairy allergens.

It was heard how it was possible that Benedict took a sip of the drink when his back was turned away from the teacher.

The school’s usual procedure of giving Benedict his milk was not followed on the day of his death because the milk was poured into his cup in the staff room rather than in the classroom and given ‘directly’ to him, the jury concluded.

Benedict’s mum said the school was given a management plan for his allergic reactions, and said vomiting was ‘always’ the first symptom.

It was heard that Benedict loved school, was ‘extremely bright’ and was ‘thriving’ in the three months he spent there before his death.

The Benedict Blythe Foundation was set up in his memory and, along with The Allergy Team and the Independent Schools’ Bursars Association (ISBA), launched the schools allergy code last year to set out how schools can keep pupils safe.