An inquest is expected to hear how a teenage pupil with severe allergies and asthma died after falling ill in a school detention just months after his health care plan was mistakenly downgraded.
Nasar Ahmed was in an exclusion room with other pupils at Bow School in east London 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.
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 an inquest into his death at Poplar Coroner's Court was told how school nurse Goddard Edwards mistakenly assessed Nasar'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 incomplete records of the boy's medication when it was discussed with his parents during a meeting six months before he died, and the plan failed to mention use of an EpiPen, which Mr Edwards accepted was "an oversight on my part".
The inquest also heard there were no requirements for staff on duty during the detention to know of Nasar's medical requirements.
Teacher Arlette Matumona, responsible for pupils' medical needs, was unable to say whether staff supervising the exclusion period had looked at the school's information system to check on Nasar's medical needs.
The inquest, which is expected to conclude on Friday, is due to hear evidence from a pathologist and members of staff at the school.