Sarah Reading was just 17 years old when she sat down to a slice of lemon meringue pie. It seemed harmless enough, but within hours she was dead - the victim of a severe allergic reaction to peanuts.
Such extreme cases of anaphylactic shock are rare, but the prevalence of serious allergies is anything but.
More than 25,000 people in England have been diagnosed with a peanut allergy, according to a Department of Health study, and among under-20s, males are almost 30 per cent more likely to suffer from the allergic condition than females. Children from affluent backgrounds have the highest rate of peanut allergy, the study found.
If an episode occurs in the classroom, it is the school's responsibility to know what to do. It is a prospect that strikes fear into even the most well-prepared teachers.
"I always seem to have one pupil who's allergic to peanuts, so I do the EpiPen (adrenalin auto-injector) training session every year," says one secondary school teacher from Bedfordshire, who asked to remain anonymous.
"But I live in terror of actually having to give the injection. I can't even remember how to do it a week after the training, let alone in a crisis."
A recent survey by the GMB trade union, which represents school support staff, found that 57 per cent of school secretaries, teaching assistants and school support workers do not have the relevant training for medical procedures (including administering adrenalin injections) despite often being called upon to do so.
David Reading, Sarah's father, wants to buck this trend. Back in 1993, he had not even heard of anaphylactic shock. His daughter Sarah had suffered from eczema as a child and had asthma all her life, but her hunch that she was allergic to peanuts had never been taken seriously. So when she ate a pudding with a topping of crushed peanuts in a restaurant, no-one panicked. But when she got home, she complained of feeling unwell. Within minutes, she collapsed and died.
Doctors initially thought an asthma attack was to blame, but a pathologist later concluded that it was a case of peanut-induced anaphylaxis. Around the time of Sarah's death, at least four other British teenagers died of anaphylactic shock. One was a 16-year-old girl who collapsed at her school in Dorset having eaten a biscuit that contained traces of peanut.
Despite the death toll, Mr Reading struggled to unearth information about the killer. As he researched the topic, he was shocked at the lack of knowledge in the food and catering industries, plus the dearth of expertise among GPs.
As a result, he set up the Anaphylaxis Campaign in 1994 with a group of other concerned parents to try to fill that void. "Within a year I was receiving 60 to 70 letters a day from parents whose children had severe allergies," he says. "They were receiving minimal help from restaurants, schools and doctors."
Today, there are more than 7,000 members of the Anaphylaxis Campaign. Most members have a child who is allergic to nuts, but severe reactions to eggs, milk, shellfish, sesame seeds, kiwi fruits and insect stings are also common. Fortunately, most will not prove fatal: about six deaths a year are reported in the UK.
But there are many more who face frightening, potentially lethal anaphylactic reactions. Over the years, an increase in attacks means schools have had to become much more aware of the possible dangers.
A case in point is Heatherside Infant School in Fleet, Hampshire. The 300- strong school has up to six pupils with serious allergies at any one time, and takes its responsibilities seriously. Parents of children with allergies are invited to one-to-one meetings three months before their child starts. It gives them an opportunity to share concerns and put forward any requests.
"The dialogue starts early and continues throughout their time here," says Sarah Woodcock, the school's administration manager, who has a nut and split-pea allergy herself. "It's never seen as a problem or something that teachers are nervous about managing."
Thorough training and good organisation are key to putting parents' and teachers' minds at rest. A nurse runs a voluntary course on anaphylaxis every year, which looks at how adrenalin should be administered, plus how to spot and respond to an attack. The majority of dinner ladies, teachers and support staff attend.
In addition, every member of staff knows which pupils are affected, and they are reminded by photos in the medical room. The catering company talks to parents directly about their requirements and provides lists of ingredients if required.
Staff also know where the EpiPens are kept: in clearly labelled plastic boxes in a high, unlocked cupboard in the medical room. And if the pupil is in the process of being diagnosed, parents are asked to provide teachers with a bottle of Piriton, an over-the-counter allergy treatment, as a precaution.
Avoidance is Heatherside's first line of defence. "We try to be a nut-free school," explains Ms Woodcock. "We ask parents not to include nuts or things that may contain nuts in their children's lunchbox. Our dinner ladies are very vigilant: checking the lunchboxes and making sure pupils never swap food."
Sometimes, she admits, they can be over-vigilant. One pupil was separated from his peers because of a suspect peanut butter sandwich. In fact, it was Marmite mixed with Dairylea spread.
Still, Ms Woodcock would rather be safe than sorry. "At this age, children are always kissing and cuddling each other," she says. "We know that any remnant of peanut on the lips of one child could be enough to trigger an attack in another. We try not to turn it into a traumatic event for anyone, but just washing hands and mouths will minimise the risk."
Sue Clarke, a nurse adviser for the Anaphylaxis Campaign, confirms that schools are much more clued up these days. When her son Chris, now 24, was at school, that was not always the case.
Following several near-fatal incidents as a baby, Chris was diagnosed with a severe allergy to milk and eggs. In the absence of any other training, Ms Clarke took it upon herself to teach his school about the risks.
Despite the training, his teachers still got it almost fatally wrong on occasion. One decided to use eggs in a craft project in the run up to Easter. Left unsupervised for a minute, one pupil smashed raw egg onto his hands and slapped it on Chris' face.
The then 11-year-old ran off to wash his face. Initially he seemed all right. But once on the school bus at the end of the day, he suffered an attack. He was hospitalised and off school for a week.
Three years later he ate what he believed to be seven plain chips in the school canteen. Fifteen minutes later, he was feeling unwell. His teacher sent him to the school office with a friend - the worst thing he could have done.
One of the most dangerous symptoms of anaphylaxis is hypotension, or low blood pressure. By moving the pupil, the allergic reaction can be accelerated and cause them to collapse - which is what happened to Chris en route to the school office. A member of staff then phoned his mother instead of the emergency services.
"It can be difficult for schools because it is hard to recognise that an otherwise healthy looking child has a life-threatening condition," says Ms Clarke. "It's not just about taking it seriously. It's about thinking ahead and having a contingency plan."
Some schools are more open to the idea than others. Ms Clarke, who has developed an on and offline training pack for school nurses through the Anaphylaxis Campaign, has held workshops that have attracted 75 members of staff at some schools. Others have brought in just two.
The Government recommends that teachers go on courses of this type and volunteer to administer medication, but Ms Clarke would like to see a more whole-school approach.
"Teachers may not feel it is their responsibility to care for a sick child, but I think most would recognise that they need to have the skills to know what to do," she says. "Being in loco parentis means they cannot take short cuts."
This culture of care would mean everyone from the caretaker to the cleaners would attend a course. Peanuts on the floor would be cleaned up as soon as possible, and food traces quickly cleaned from table tops.
Passing responsibility on to a first-aider may not always be possible. If a child collapses in class, teachers need to know how to respond immediately.
In the past, teachers could dismiss the need for training because the chances of encountering anaphylaxis were so rare. That is no longer the case.
Despite limited data on trends in anaphylactic shock, hospital admission rates for the condition rose by 700 per cent between 1990 and 2004, according to research by the Resuscitation Council UK. But pupils with regularly reviewed individual care plans have fewer, less severe reactions, further studies by Cambridge University found.
Taking responsibility for anything as unpredictable and potentially life- threatening as severe allergy is a lot to ask of busy teachers. But with proper management and good training, tragic events - like the death of Sarah Reading - need never occur again.
HOW TO BE ALLERGY SAFE
- Allergen avoidance: the simplest and most effective way of avoiding a reaction.
- Risk assessment: to be taken in addition to the school's health and safety risk assessment.
- Regular communication with pupils and their parents: they are often the experts - let them help you.
- Keep kitchens and dining areas clean of food allergens: minimise hygiene and cross-contamination risks.
- Knowledge of ingredients of school meals: staff should keep ingredient lists to hand.
- Easy access to emergency medicines: know where medicines are kept and who is trained to administer them.
- Regular staff training: for all staff at least once a year, delivered by a healthcare professional. Staff volunteers can be trained to administer adrenalin injectors.
- Bans: think carefully before banning nuts in school. It is impossible to provide a nut-free guarantee so this could lead to a false sense of security. Allergic pupils are more likely to learn avoidance strategies in an environment where allergens may be present.