A school nurse admitted mistakenly downgrading a health care plan for a teenage boy with severe allergies and asthma months before he died after falling ill during detention.
Goddard Edwards, who worked for a private company, assessed Nasar Ahmed's allergy plan as mild to moderate rather than severe, despite him being allergic to a wide range of foods and needing access to an epipen.
He also failed to follow up on gaps in details about the boy's medication when it was discussed with his parents during a meeting at Bow School in east London.
- Nasar was in an exclusion room with other pupils when he became unwell and collapsed in November 10 last year
- He was rushed to hospital and put on oxygen but a brain scan showed the 14-year-old was unresponsive and he died on November 14
- An inquest into his death at Poplar Coroner's Court also heard there were no requirements for staff on duty to know of his medical requirements
Teacher Arlette Matumona, responsible for pupils' medical needs, was unable to say whether staff supervising the detention had looked at the school's information system to check on Nasar's medical needs.
The inquest heard the Year Nine pupil had asthma, severe eczema and a host of allergies, including to fish, nuts, wheat, apples and oranges.
He used inhalers, his mother carried two epipens and the school had two more epipens if he showed symptoms of an anaphylactic allergic reaction.
But at a meeting on May 3 2016 with Nasar and his mother, Mr Edwards used an incorrect form when assessing his allergies, downgrading his case from severe to mild to moderate.
He also failed to follow up on incomplete records of Nasar's medication that needed to be kept at the school, the inquest heard.
Use of an epipen was also not mentioned, and Mr Edwards conceded he made a mistake.
When asked how he would characterise his care for Nasar, he said:
Coroner Mary Hassell told him she was surprised to hear that following the catalogue of errors, to which he answered:
The inquest continues.