Raw jelly choking risk ‘not sufficiently highlighted’

Nursery World understands that in 2014 a Prevent Future Deaths (PFD) report on raw jelly was completed by the coroner in charge of the inquest into the death in 2012 of Tiya, who choked on a jelly cube.

The inquest jury returned a verdict of accidental death ‘contributed to by neglect’, after Dicky Birds failed to supervise Tiya for up to 75 seconds during sensory play.

Westminster coroner Dr Fiona Wilcox is understood to have raised a number of concerns in the PFD, including a lack of any warning on jelly packaging.

It is understood to have been sent to the Food Standards Agency (FSA), Ofsted and the Local Government Association (LGA), but some early years organisations are unaware of it.

A ‘call to action’ by the Child Accident Prevention Trust (CAPT) was announced in May last year, which coincided with professional bodies such as Pacey pointing out the risk of the foodstuff, but seemingly no new official guidance has been put in place.

Liz Bayram, PACEY’s chief executive, said she would most likely back a warning on jelly packaging, adding that she had not seen the PFD.

Ms Bayram said, ‘Putting a warning on jelly packaging – that may be a good thing.

‘It would be really important to know what’s happened as a result of the coroner’s report. It’s very difficult to know what to suggest, without having seen it.

‘Organisations respond to documents with clear recommendations, and without that clarity the system does start to creak. We do what we can, but that’s not the same as a formal process from a regulatory body.’

Dicky Birds was last month ordered to pay nearly £200,000 in fines and costs after admitting health and safety breaches.

The thus far publicly unavailable PFD report could be considered a missed opportunity to prevent future deaths. Legislation was introduced in 2013, under Regulation 28 of The Coroners (Investigations) Regulations, which requires coroners to complete PFDs and send them to the chief coroner, who publishes them on the Courts and Tribunals Judiciary website.

NO COPY

Nursery World has been unable to obtain a copy of the report. A note on the Judiciary’s website said reports had only been uploaded since 2015, and progress was being made with earlier ones. However, a spokesman was unable to confirm whether this report had indeed been received, because of the long Easter break.

Hayley Davies, the coroner’s officer who investigated the Chauhan case, would not confirm whether a report had been written or sent.

Ms Davies said, ‘I understand that all Regulation 28 reports are published in a partially redacted form on the chief coroner’s website. I cannot comment with regards particulars of any case.’

A Judiciary spokesman said, ‘Generally, the chief coroner is in favour of transparency.’

Dicky Birds, while underlining that it had accepted its own failures and gone to great lengths to minimise risk in its setting, has also called for more to be done to raise awareness of the risks of sensory food play, particularly with raw jelly.

The nursery would like to see the FSA put ‘concerted pressure on the manufacturers of jelly products to place clear warnings on their packaging about the very specific choking risks of raw jelly cubes in young children’.

It added that it would like the LGA to ‘ensure that all local authorities write to every registered childcare setting in their area alerting them to the specific choking hazard of raw jelly cubes’.

The nursery also urged that the EYFS should ‘specifically preclude the use of sensory food play and particularly raw jelly’, a ban which the setting has put in place.

Commenting on the last suggestion, PACEY’s Ms Bayram said, ‘There’s an opportunity here to learn from the event and make sure it doesn’t happen again.

‘My balance to that would be that the EYFS is very clear about managing risk and about what settings need to do.

‘Any new information specific to raw jelly would be helpful, but I would not want people to rule out food play. We have to balance the benefits of using food as part of sensory play with the risk, and recognise that the EYFS and good practice of settings already have that well covered.

‘The specific issue is making sure people understand the risk of raw jelly, and raising awareness of the specific risk, and that’s what we’ve done.

‘Precluding food in sensory play in the EYFS is a bit extreme, a step too far.’

Dicky Birds provided Nursery World with a summary list of the coroner’s concerns compiled by its lawyers, which includes a reference to jelly packaging carrying a warning:

CORONER’S CONCERNS

• That nurseries, other childcare and school settings and even parents may be using raw jelly during play without appreciating the special risks of choking that a cube of raw jelly presents
• That packets of raw jelly do not contain a warning that cubes of jelly present a choking risk to children
• That raw jelly cubes may be used in play with young children without sufficient supervision
• That local authorities and Ofsted ensure appropriate warnings are communicated to nursery settings

Organisations to which PFDs are addressed are required by the regulations to respond to the coroner within 56 days. Dicky Birds is aware of responses by Ofsted and the FSA, but not the LGA.

LACK OF INFORMATION

Kate Brayne, an early years consultant based in Bath, called for the coroner’s report to be circulated, along with a national media campaign.

Ms Brayne said, ‘Certainly in Wiltshire no message has come down through the childcare officers from the director of children’s services.’

According to Dicky Birds, the FSA said in its response to the report that it had highlighted the concerns to all local authority environmental health departments, and written to relevant food trade bodies for their ‘information and consideration’.

Ms Brayne added, ‘Most settings have very little contact with the local environmental health inspectors, apart from “scores on doors” inspections, and I don’t think they are an agency we would necessarily think to turn to first for messages about food safety – apart from poisoning episodes.

‘Again in Wiltshire the Department of Health message does not seem to have filtered through either. Of course with the massive cuts to local authority spending and consequent redundancies, most settings that are not in need of extra support barely see a childcare officer any more. When I had a quick look online, there were scores of examples of jelly play, with not a single warning of risk.

‘It would be extremely helpful for the coroner’s report to be circulated to all early years settings. I don’t think that enough settings are aware at all. Maybe it is time for a media campaign – if this was covered on the national news just on one day I think the message would pass down really quickly, because actually it is more the parents who need to know the risk than settings. A busy mum is more likely to leave a toddler alone for a minute while she puts the washing on than a setting is. And whereas most parents do now know about grapes and cherry tomatoes, raw jelly just isn’t up there on the radar.’

Helen Hodsdon, a lecturer and early years assessor, questioned whether there are enough resources at local authority level, adding, ‘Most, if not all, English local authorities have cut budgets and support for all EYFS settings, so I’m unsure how they could meaningfully work with CAPT to raise awareness.’

A Dicky Birds spokesman said, ‘While the nursery is keen to do what it can to raise awareness among the childcare community and ensure that any lessons learnt are shared, they are conscious that doing so too soon after the conclusion of the health and safety proceedings may cause Tiya’s family unnecessary upset.

‘That is why they have decided to pause for the time being and carefully consider the best way forward, whilst minimising any impact on the family.’

The Department of Health, FSA, Ofsted and the LGA were not available for comment at the time of going to press.