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Family Press Release - Prevention of Future Death Notices (PFD).

MEDIA ADVISORY 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.  



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