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Anaphylactic Shock

1 pm

Mr. Phil Willis (Harrogate and Knaresborough): In 1993, 17-year-old Sarah Reading died after eating a lemon meringue pie in the restaurant of a well-known departmental store. She suffered an anaphylactic shock--an extreme allergic reaction when blood pressure falls rapidly and the patient quickly loses consciousness. The simple dessert that she ate on that day contained peanuts, to which Sarah was fatally allergic. That is an extreme case, but is certainly not rare. In 1995, Louise Westlake was served bread containing walnut butter at a dinner in a Manchester hotel and died. She knew that she was allergic to nuts, but did not expect to find nuts in butter. Laura Thesher was 19 and in her second day at St. Catherine's college in Cambridge in 1998. The menu said:

It is estimated that about 1 million people suffer allergic symptoms that could be life threatening. One in 6,000 cases treated in casualty departments in our hospitals is the result of anaphylactic shock. One in 200 children are affected, and for some the threat to their lives is very real and constant. However, nationally too few allergy consultants are available, and the GPs in my constituency report that referrals for specialist allergy care is overwhelming, yet specialist care packages can make a life threatening condition manageable. Will the Minister tell the House what steps the Government are taking in the NHS plan to recruit and train consultants, and to offer a more rapid and sophisticated service in the treatment of allergies?

Part of the management of allergies is the avoidance of products that can cause anaphylactic shock. Avoidance is not helped by the quality and legibility of the allergen risk labelling. Far too many major United Kingdom food manufacturers fail effectively to communicate allergen risks on their products. The font may be too small, the information is often hidden under wrapping or away from the ingredients list, which is where sufferers will automatically look for information. It is crucial that labelling on foodstuffs and loose ingredients, particularly in restaurants and food chains, is not only mandatory but conforms to strict guidelines laid down by trading standards.

It is clearly nonsense that failure to declare a genetically modified ingredient when there is no proof of harm can result in a £5,000 fine, whereas the display of information about allergens when death is known to occur is an optional extra. Will the Minister tell us what steps are being taken to make food labelling for allergens mandatory, and to ensure that environmental health officers are effectively trained to carry out inspections of food premises?

For adults managing a life style with the possibility of anaphylactic shock, the risk is problematic but bearable. Tens of thousands cope with that problem every day, and most lead perfectly normal lives. They do so often with the help of an epipen auto injector or a similar

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device that enables a severe anaphylactic shock to be immediately stabilised with an injection of adrenaline until hospital treatment can be secured. The adrenaline epipen is a security policy that gives enormous comfort and security to allergy sufferers. Those at risk always carry their epipen, and a 10-second self-administered dose is usually sufficient to stabilise the condition.

However, failure to carry or have access to an epipen could prove fatal, as it was for Nicola Ratcliffe, a first-year student at Durham university. She ate an Indian meal with friends, and although she knew that she was subject to anaphylactic shock, she had left her epipen in her room. She died aged 18, before treatment could be administered.

The training of first aiders in the use of epipens and their availability when training has taken place could save a person's life in the workplace. It is on a par with a defibrillator. As recently as 5 February this year, the Health and Safety Executive supported work-based training by St. John Ambulance in the use of epipens in the workplace. Will the Department of Health consider extending first aid training to include the use of epipens in the workplace? Although no one would consider making them freely available, surely trained users in large food courts would be of particular value to the public.

The principle reason for seeking this debate is to highlight the problems faced by children subject to anaphylactic shock. It appears that children can and are being discriminated against. Only last month, Martha Atkins, a pupil at St. Paul's primary school in Radlett, was forced to move to another school because staff would not let her use an epipen in an emergency, and they refused to administer it themselves. Although such action by a school is rare, and Martha has now found a place in another school where staff will use an epipen in an emergency, the case highlighted the very real confusion that surrounds the treatment of anaphylactic shock in children.

Department for Education and Employment guidance says that children with medical needs

However, the first aid at work regulations, which go back over 20 years and have not been amended in that time, do not permit invasive techniques, even in the case of anaphylactic shock, even though they are known to be an effective treatment and a life saver. There is no legal or contractual duty on school staff to administer treatment or supervise children when taking it, although there is of course a common law duty to act as any prudent parent would, and that includes administering medicines in an emergency.

The current state of affairs is totally unsatisfactory. Heads and teachers need to know exactly where they stand in law. Given that the Special Educational Needs

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and Disability Bill is about to enter the Commons, having gone through the Lords, will the Minister consider drafting a new clause specifically to include the emergency treatment of anaphylactic shock and the training of appropriate staff? That in itself would go a long way towards resolving the problem. Such a measure would not only clarify the present situation, but would enable teachers or support staff to be trained in the most simple of procedures and to be insured against any possible claim for negligence. Such clarification would bring huge comfort to thousands of parents and would remove from those children's minds the nagging doubts about the threat of an allergic reaction.

Finally, I want to draw the Minister's attention to the appalling situation surrounding Mathew Johnson, one of my young constituents. Mathew is 10 years old and suffers from a severe tree nut allergy. For the past four years he has been denied access to local authority leisure schemes--not because of his allergy, or because there is anything else wrong with him, but because of his need to use an epipen if he inadvertently goes into anaphylactic shock. The leisure centre staff say that Mathew can take part only if he is accompanied by a parent--both his parents work-or a trained nurse at the cost of £100 to £150 a day. Otherwise, he has been offered a place on a one-to-one scheme for children with learning or physical disabilities. That is totally inappropriate for a young boy who wants to play with his peer group and take part in activities.

Mathew is a normal child. He is not ill. There are thousands of Mathews up and down the country. There are 12 in my constituency alone, and I have been informed of others in Leeds, Birmingham, Croydon and Tonbridge. No child should be discriminated against in that way. It is a betrayal of the United Nations convention on the rights of the child, article 31 of which states:

I understand the situation of staff leading leisure or sporting programmes or playgroups. They are placed in an impossible position. I do not object to their trade association instructing them not to use these invasive devices. The law should protect them, and they ought to be insured against negligence. They should also receive formal training. Things could be so different. Extending existing legislation and DFEE guidance to cover all local authority approved leisure and play schemes would help. Including specific regulatory provision in the Special Educational Needs and Disability Bill to include leisure and play schemes would certainly help. Ensuring that all first aid training includes the administration and use of epipens and similar devices

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would take away much of the mystery and mystique. Establishing a common code of practice that provides the basis for local authority legal cover for all staff using epipens, provided they have been trained, would solve the problem in a stroke. The outdated first aid at work regulations that do not permit invasive techniques, even for anaphylactic shock, clearly need to be updated.

Anaphylaxis is an increasingly common condition affecting children, and it is on the increase. It is easily managed with adrenaline. Surely a caring Government can manage their responsibility to those children affected.

1.13 pm

The Minister of State, Department of Health (Mr. John Denham) : I congratulate the hon. Member for Harrogate and Knaresborough (Mr. Willis) on securing this debate. He has raised a wide range of important issues, and has illustrated them by reference to some distressing deaths that have occurred as a result of anaphylactic shock. He has also talked about the interesting case of his constituent who has not been able to get on to play or leisure schemes because carers are not prepared to administer adrenaline injections for anaphylactic shock. As of today, it is the only case that I am aware of that has been brought to the Department's attention, but that does not diminish its importance and the need to discuss the issues that the hon. Gentleman has raised.

Every parent in the country is apprehensive about how they would cope if a sudden medical emergency, such as an anaphylactic attack, befell one of their children. Our children's health is so precious to us that we want to be reassured that the NHS, schools and others can cope in such a situation. About 1,000 children aged 15 and under are admitted to hospital each year as a result of anaphylactic shock.

Anaphylaxis is an acute, immune reaction needing urgent medical attention that may occur in children who suffer from severe allergies. When such severe allergies are diagnosed, the children concerned are made aware from a very early age of what they can and cannot eat or drink. I am happy to say that, in the majority of cases, children go through the whole of their school lives without incident.

The most common cause of an anaphylactic attack is a severe allergy to food. The hon. Gentleman talked about nut allergies, but certain drugs such as penicillin, and the venom of stinging insects, such as bees, wasps or hornets, can also result in an attack. In its most severe form, the condition is life threatening, but it can be treated with medication. That may include antihistamine, adrenaline inhaler or adrenaline injection, depending on the severity of the reaction. Most patients are normally prescribed a device for personally injecting adrenaline. The device looks like a fountain pen and is pre-loaded with the correct dose of adrenaline. It is not possible to give too large a dose when using this device.

I should like to say a little about food allergies in general, and about what we are doing in conjunction with the Department for Education and Employment and voluntary organisations, such as the Anaphylaxis Campaign, to cope with these attacks in a school setting. I should also like to talk about the work of the Food Standards Agency in increasing our knowledge of the causes of food intolerance.

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Food allergy or food hypersensitivity are broad terms that cover a range of abnormal immune responses to foods. Such terms are often misused and can sometimes be confused with other conditions that do not involve an immunological response, such as food intolerance, food poisoning or digestive tract disorders. A wide range of foods has been implicated as causing food allergies, including milk, eggs, peanuts, fish, shellfish, nuts, seeds and fruit. It has been reported that over 90 per cent. of adverse reactions in children can be attributed to four major foods: nuts, eggs, milk and soy.

Nut allergy is an umbrella term given to hypersensitive reactions to proteins found in nuts and peanuts. Oils extracted from nuts and seeds, such as sesame, are sometimes used by food manufacturers in the unrefined form. Allergens may therefore be present in a surprisingly wide and varied range of foodstuffs. Testing for an allergy to nuts will usually be combined with a general allergy test. Unfortunately, many nut allergy sufferers only learn of their allergy when they experience an adverse reaction for the first time. Once the allergen is identified--for example, arachis oil in peanuts--allergy clinics can begin advising on the most effective treatment. Tests are usually carried out in a primary care setting, although allergy clinics can provide more advanced and specific tests.

The Food Standards Agency is doing important work to improve our understanding of food allergy and intolerance. It is concentrating on three areas. The first is raising awareness of the condition among the public; the second is funding research into the causes of food allergy; and the third is encouraging informative labelling.

The FSA is continuing the "Be allergy aware" campaign launched in 1997 to raise awareness of the problem of food allergy among the catering industry. The campaign has taken the form of posters, leaflets and stickers, which were sent to over 200,000 catering establishments, including schools, with advice on how caterers can help those with severe allergies. The FSA also funds research on allergy and intolerance, with particular emphasis on severe allergies. A large programme of research on food intolerance and allergy, costing around £1 million a year, is currently under way.

The Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment published a report in 1998, which addressed some of the issues behind the possible causation of peanut allergy. A further report on adverse reactions to food and food ingredients was published in July 2000. The FSA has welcomed those reports, as they help to raise awareness of the problem among consumers, the medical profession and the food industry.

The FSA has already taken on board a number of the research recommendations outlined in the COT report. It invited proposals for some of those recommendations in its research requirements for 2000-01. That research will help to formulate future FSA policy on food intolerance.

The FSA is also working to ensure that labelling is informative, so that allergy sufferers get the information they need. The UK has been urging the European Commission to bring forward proposals for changes in EU law so that certain named allergenic ingredients are always clearly and recognisably labelled. I acknowledge

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the point that the hon. Gentleman made, and there is a need to press for effective action in this area. It is also worth recognising the problems that can be caused by the over-use of the commonly seen label "may contain". There is a danger that that may restrict consumer choice unnecessarily, so accurate and safe labelling is important for people who are prone to this reaction.

The hon. Gentleman also talked about allergy clinics and full-time consultant allergists. There are currently about 90 NHS allergy clinics in England and Wales, few of which have a full-time consultant allergist in post. The demand for them is high, and there can be lengthy waits. The process of confirming the source of an allergen is sometimes lengthy and difficult. Clinical immunology and allergy has recently been recognised as a separate medical specialty. Post-graduate training courses on allergic diseases are now available. It takes many years for a senior house doctor or registrar to become a fully qualified consultant. At least that process is under way, and we will be able to plan for an expansion of fully trained consultants in the years to come. That is one of the provisions to which the extra investment in the NHS can sensibly be applied.

I should like to deal with the individual case that may have given rise to this Adjournment debate, and was previously raised by the hon. Gentleman in an early-day motion. If a child has an anaphylactic attack outside school hours, I would expect, and I am sure that the hon. Gentleman would agree, that the child's parent or guardian would be the person best able to deal with it. If the attack is severe, the child's own GP or local accident and emergency department should be contacted for advice and, if required, treatment. However, that cannot apply in some settings.

In 1996, the Department of Health and the Department for Education and Employment issued joint guidance "Supporting pupils with medical needs in schools". The guidance was welcomed by the Anaphylaxis Campaign, and was sent to health authorities and local education authorities. It covers treatment and the development of health care plans for pupils suffering from potentially life threatening medical conditions, including anaphylaxis.

The guidance suggests that if the child is not old enough to carry his own medication, it should be kept in an accessible place. It says that the injection should be given on a purely voluntary basis. Although aimed primarily at schools, the guidance was also recommended to special schools, nursery schools and further education colleges. It was produced after extensive consultation with interested parties, including professional bodies and voluntary organisations such as the Anaphylaxis Campaign.

The guidance makes it clear that each school should have an effective policy for ensuring that those pupils with medical needs receive proper care and support at school. Formal systems and procedures, drawn up in partnership with parents and staff, should underpin the policy. The objective of the policy should be to encourage the child's regular attendance and participation in school life.

Existing practice in schools is good, and is based on good communications and good protocols. Many children with long-term medical needs may not require medication during school hours, and when they do, they

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can administer it themselves. The hon. Gentleman was a head teacher, so I am sure he agrees that schools should encourage that approach, so that the child does not feel different, or excluded from the normal run of school life.

On the legal issues, as a general rule school staff should not administer medication without having had appropriate information and training. The Medicines Act 1968 places restrictions on dealings with medicinal products, including their administration. There are exceptions for the administration of certain prescription only medicines in life threatening situations.

However, there is no legal or contractual duty on school staff to administer medicines, or to supervise pupils taking them. That is a purely voluntary role. I have some misgivings, which I am sure are shared, about allowing unqualified or untrained staff to administer prescription medicines as a matter of routine, which could be dangerous. That would be a cause for concern. Normally, the local health authority or trust can advise the school of the main contact to provide the necessary medical support to the school. It may be a school nurse provided through the school health service.

If pupils have medical conditions that, if not properly managed, can limit their access to school, it is helpful for schools to draw up individual health care plans. These should give school staff sufficient information to understand and support a pupil with long-term medical needs. Such plans should be prepared in conjunction with parents and the child's medical advisers, and should set out the measures needed to support the pupil in school. As a matter of routine all schools must have a clear procedure for summoning an ambulance in an emergency. In the unlikely event of a severe anaphylactic reaction, immediate medical treatment may be necessary while waiting for the ambulance to arrive. The child's doctor will prescribe medicine--usually in the form that I described earlier--in the event of an allergic reaction.

Many hundreds of children in the nation's schools are at risk of anaphylaxis. The vast majority of them are happily accommodated in mainstream schools. That is

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largely due to good communication and consensus between parents, teachers, medical advisers and education authorities.

Mr. Willis : Could the Minister address the specific issue of children who are not in school, but who are in local authority play schemes, leisure centres and other settings? It is those staff who need protection under the law.

Mr. Denham : The hon. Gentleman anticipates my next few remarks. Existing practice, albeit within the existing legal framework in schools, is good and seems to work based on good communications and good protocols. There is an argument, as put forward by the hon. Gentleman today, that that practice should be extended to out-of-school and pre-school activities. The Anaphylaxis Campaign is keen and willing to get involved and to help iron things out. In the past, it has intervened when parents have raised an issue. It would like guidance to be issued similar to that issued to schools. I also acknowledge that St. John Ambulance and the Red Cross would be willing to provide training in administering adrenaline shots. They are entitled to do that already, and the Anaphylaxis Campaign is very supportive of that.

One of the purposes of Adjournment debates is to raise issues that may not have otherwise appeared on the agenda. I am unable to commit the Government to taking such a route, but I recognise the arguments that the hon. Gentleman has raised based around that individual case, and I give him a commitment to consider the arguments for extending the guidance, if appropriate, to other settings. I shall write to him in due course when my colleagues and I have had a chance to consider the issue.

The Special Educational Needs and Disability Bill is the responsibility of colleagues in another Department, but I shall draw the hon. Gentleman's remarks to their attention. I shall write to him on the issue of the first aid at work regulations. I am not clear whether they are the substantive obstacle to improving the quality of provision in the workplace, but I undertake to consider those issues and get back to him.

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