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Oliver's Inquest...

The latest information on Oliver's inquest proceedings.


Any media enquiries relating to Oliver's criminal case or

inquest can be made to our legal representatives at Leigh Day or on 07498 250840.

Monday 3rd June 2024

Parents of Oliver Steeper, who died after choking at a Kent nursery, welcome coroner’s concerns over weaning training for early years workers 


The parents of Oliver Steeper have welcomed a coroner’s concerns over training for early years staff in emergency first aid and safely weaning babies onto solid food after the inquest into his death. 


Nine-month-old Oliver, known as Oli, died after he choked on a meal of chopped pasta Bolognaise fed to him by staff at Jelly Beans Nursery in Ashford on 23 September 2021. 


On 24 May this year, the inquest found that Oli, who was eating only pureed and appropriate finger food at home, died in hospital from brain damage after suffering cardiac arrest as a result of the choking incident.   


Following the inquest, Area Coroner for Central and South East Kent, Katrina Hepburn, has sent a Prevention of Future Deaths report to the Department for Education, which is responsible for early years education and training. The report highlighted the following arising out of the evidence heard at Oli’s inquest;   


  • It was not clear that the nursery staff appreciated the importance of mirroring weaning at home with weaning at nursery.  


  • The nursery and its staff did not appear to ensure that detailed and accurate information about a child’s individual weaning stage was elicited from parents, recorded, audited, reviewed and applied.  


  • It was not clear that the nursery staff appreciated the importance of eliciting and recording this detailed information from the family and circulating it with other staff members. 

  • Despite the nursery staff members having levels 1, 2 and 3 Diplomas in Childcare and Education, there was limited evidence of any knowledge or training on the stages of baby weaning and the risk of a child choking on food.  


  • As such, the coroner felt it was not clear that the content of those qualifications adequately covers stages of weaning and how to safely wean in the nursery environment.  


  • The coroner went on to say that even if the training does cover this, it is not apparent that any refresher training is provided to nursery staff holding these qualifications, to ensure that they are up to date in their knowledge, i.e. continuing professional development. 


The coroner has submitted her report to the Department of Education, which is responsible for the Early Years Foundation Stage Statutory Framework, and for Diploma qualifications in Childcare and Education, both of which cover training for nursery staff. 


Oli’s father, Lewis Steeper said:  
“As a family we are pleased that concerns around Paediatric First Aid (PFA) Requirements, the Paediatric First Aid Training Validity Period and Staff Education Regarding Weaning Stages have all been identified as concerns, as we also had the same concerns leading out of the inquest. Since losing Oliver after the choking incident at the Jelly Beans nursery in September 2021, our mission has been to use his memory to make childcare settings safer places for children at such an important and vulnerable stage in their life, specifically around the preparation of food.  


“In due course, we look forward to the response from the Department for Education and would welcome any meetings to look at better education and awareness for those who work with the youngest of children.”  


The Steeper family’s solicitor, Leigh Day partner Jill Paterson said:  


“We welcome the coroner’s further prevention of future deaths report which clearly shows the vital importance of food preparation and knowledge of the weaning process amongst nursery staff.  


“As the coroner states in her report, it was not clear that staff at Jelly Beans Nursery fully appreciated the importance of replicating the weaning process put in place by parents for babies at home, to make sure it was mirrored in a nursery setting.    


“It is vital that lessons are learned from the circumstances surrounding Oli’s death to help ensure a similar tragedy does not happen again.”    


Area Coroner Katrina Hepburn’s report also raises concerns over the following issues which she previously stated at the conclusion of the inquest:  


  • Early years childcare providers only being required to have one member of staff with a valid paediatric first aid certificate on site, despite the fact they could be responsible for large numbers of children and the risk that young children, particularly weaning babies like Oliver, will require emergency first aid due to sudden choking. In the 20 years between 2001 and 2021, the Office for National statistics recorded 40 deaths due to choking in infants (children aged less than one year) in England and Wales. 


  • When confronted with an emergency situation with a choking child, even staff with a valid paediatric first aid certificate were not able to comply with Resuscitation Council UK guidelines and the coroner recommended regular refresher courses. 


The Department of Education now has a duty to respond to the report with details of action taken or proposed to be taken within 56 days of the date of the report.  




24/05/24 - Oliver's Inquest 

The jury at Kent and Medway Coroner’s Court found Oliver died after inhaling food and choking as he was being fed by staff at Jelly Beans Day Nursery in Ashford, Kent on 23 September 2021.  

Oliver, known as Oli by his family, was treated by paramedics at the scene, and William Harvey Hospital, before being transferred to Paediatric Intensive Care Unit at Evelina Children’s Hospital in London. Medical procedures later discovered a significant amount of food debris within Oli’s lungs, some of which doctors were unable to remove. He was unable to survive his injuries and died at Evelina Hospital six days later.  

Returning a conclusion of misadventure, the jury ruled that Oli, who was only eating pureed and limited finger food at home, died from brain damage caused by a lack of oxygen after suffering a cardiac arrest as a result of the choking incident.


Area Coroner Katrina Hepburn said she would issue a prevention of future of deaths report to the Department of Education on the following issues: 

Early years childcare providers only needing to have one member of staff with a valid paediatric first aid certificate, despite the fact they could be responsible for large numbers, in this case up to 80, children. 

Even staff with a valid paediatric first aid certificate were not able to put into place recommended guidelines and recommended regular refresher courses. 


She added, “It is apparent from evidence in this case that when confronted with an emergency situation of a choking child that staff, even those with a valid certificate in place, were not able to put into place the Resuscitation Council guidelines. For example, no chest thrusts, a mouth sweep was given against the guidelines, staff were unsure of the strength of backslaps. I am concerned that even staff with valid training, who had it up to 3 years earlier, without regular refresher may not recall the finer particulars to ensure effective first aid is given.” 

The 7-day hearing at Kent and Medway Coroner’s Court in Maidstone heard that a post-mortem examination by pathologist Dr Charlotte Randall found Oli “suffered unrecoverable neurological damage” and concluded that choking had led to cardiac arrest. The pathologist confirmed that “fragments of food were removed from airways”. The jury was told Oliver had no underlying disease that predisposed him to a choking episode. 

Before the incident, Oli’s mother Zoe Steeper described to the inquest visiting the nursery on several occasions and discussing his feeding requirements with staff, telling them Oli was eating only pureed meals and limited finger food at home. At the time Oli only had two partially grown bottom teeth and was unable to properly chew solid food. Zoe recalled being told by staff this was ok because they had a blender to make pureed food on site.  

Oli attended Jelly Beans on Thursday 23 September 2021. At around 1130 that day, Zoe received a call from the nursery saying Oli had had an accident whilst eating, had choked and was being treated by paramedics. Zoe arrived at the nursery a short time later to find paramedics running to the ambulance performing CPR on Oli. Oli was then taken to William Harvey Hospital by ambulance accompanied by his mother. On arrival at the hospital, she heard from the paramedics that Oli had apparently choked on some pasta which he had been fed at the nursery. 

Doctors at the hospital were able to restore Oli’s heartbeat but advised he needed to be transferred to the Evelina Children’s Hospital in London for specialist care. Sadly, his condition worsened and on arrival at the Evelina Zoe and Lewis were informed by doctors that Oli would not survive. Over the next few days tests confirmed that Oli’s brain was irreparably damaged. Oli passed away on Wednesday 29 September 2021.   

Oliver’s parents Lewis and Zoe Steeper are represented Leigh Day partner Jill Paterson. The family have instructed barristers Helena Spector and Janine Wolstenholme of Park Square Barristers.   


Zoe Steeper said: 

“On 23 September, I dropped Oli off at nursery. He never came home again.   

“We have heard evidence in court that the nursery fed our 9-month-old baby chopped penne pasta bolognese. He choked and died. A significant amount of food debris was found blocking his lungs.    

“In Court, we were shocked to hear various witnesses give evidence about the scene of total chaos that unfolded that day in front of many other little children. Oli was only 9 months old. He was just a little baby. Why did this happen? We believe that Oli’s death was entirely preventable. 


“Oli was still on milk, and we had started to move him on to pureed and appropriate finger foods at home, always under our watchful eyes.  He had only just started teething, and only had 2 little bottom teeth that had started to grow.  We feel he wasn’t ready for the type of meal he was given, and we maintain that we never gave the nursery permission to unilaterally make that decision.   

“We entrusted Jelly Beans nursery with our most prized possession - our beautiful baby boy.  We were assured that they would look after him properly. No parent should ever leave their child at nursery for them not to come home. 


“Hundreds of thousands of children are looked after by nurseries every day in the UK.  It generates an estimated income of £4.7 billion pounds each year.  It is big business.  Oli’s case has shone a light on what we feel are loopholes in the way that nurseries are allowed to care for young children and babies.  We have waited more than two and half years for Oli’s voice to be heard. We now want to see meaningful change to ensure no other family has to go through the heartbreak of losing a baby in this way whilst in the care of others.” 

Leigh Day partner Jill Paterson said: 

“Oli’s death was an unimaginable tragedy and one that no parent should have to endure. Despite the devastating grief our clients have had to go through, they are fully committed to ensuring that important lessons are learned from this terrible incident and that nurseries and other early childhood settings become safer places in future.  

“Urgent action must be taken by all those involved in the Early Years Sector, including regulators, legislators and childcare providers, to ensure that this appalling tragedy that cost the life of a baby boy never happens again.”


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