A school nurse in England has admitted mistakenly downgrading a health care plan for a teenage boy with severe allergies and asthma just months before he died after falling ill during a detention.
Goddard Edwards assessed Nasar Ahmed's allergy plan as mild to moderate rather than severe, despite the youngster 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 on 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.
He said: "The epipen doesn't figure on this particular plan. I accept that this was an oversight on my part."
Mr Edwards also said the error with the care plan was a "complete oversight on my part", and admitted failing to follow up and review Nasar's medication needs after asking a receptionist to tell his mother she needed to bring up a new epipen and inhaler for him.
But when asked how he would characterise his care for Nasar, he said: "I fulfilled my duties. I am happy with the care I gave Nasar."
Coroner Mary Hassell told him she was "surprised to hear that" following the catalogue of errors, to which he answered: "There are some omissions with the care plan, so to go back to your question, no, there are some problems with this."
The inquest also heard Ms Matumona explain staff were told to check pupils' medical records at the start of the school year.
But she said support staff, who would not have come into daily contact with Nasar, had been on duty that day, and conceded they may have failed to check.
She said: "Perhaps they wouldn't necessarily think to check in the school system.
Ms Matumona added: "Some staff will and some staff won't check SIMS (the school's information system) as a matter of course."
Pressed by the family's lawyer, Sam Jacobs, on whether they should, she replied: "I am not sure. If you are a support member of staff who does not teach that child...
"Most of our staff would not have thought that Nasar would have to be discussed so publicly."
Asked if it was realistic for staff to remember a child's medical needs after checking at the start of the year, Ms Matumona said: "Perhaps we could have it so that it's displayed somewhere or have a list for those children in exclusion."
A PE teacher who rushed to help Nasar after he started wheezing, coughing and complaining he could not breathe in the exclusion room described how she administered first aid and called paramedics while another ran to get his health care plan.
Gemma Anderson told the inquest Nasar's condition quickly deteriorated, his breath coming in gasps every 20 seconds as he began to slip in and out of consciousness, his face turning red and foaming at the mouth.
Despite Nasar's personalised medical pack being brought it contained the wrong plan for his allergies, and Ms Anderson said she could not recall whether she even saw it as she was caught up in the emergency.
Seeing an epipen, she repeatedly asked the 999 call handlers if she should use it, but did not do so before paramedics arrived 17 minutes after being called.
Asked by Ms Hassell if seeing the correct plan would have made a difference, Ms Anderson said: "Yes, if I had seen that it would have prompted me to say to the (call handler), 'We are going to use the epipen', and not ask for advice."
Ms Hassell said: "If you had looked at the plan and it was not the one in the pack but the earlier one, which said 'if you see these symptoms, such as loss of consciousness, wheeziness and collapsing, give the epipen', would you have just then immediately given the epipen?"
Ms Anderson replied: "Yes."
The inquest heard Nasar had been put in exclusion after kicking a bin down a staircase with friends.
His father, who was summoned to the school, begged interim deputy head David Jones not to put him in detention, saying Nasar had been tired and was on medication.
The inquest continues on Friday.