The parents of a little boy who died after choking on food at a nursery have welcomed a coroner’s concerns over weaning training for early years staff.

Nine-month-old Oliver Steeper died after choking on chopped pasta bolognese fed to him by staff at Jelly Beans Nursery in Field View, Ashford on September 23, 2021.

Last month, an inquest found Oliver, who was eating only pureed and finger food at home, died in hospital from brain damage after suffering a cardiac arrest following the incident.

The inquest returned a conclusion of misadventure. The five men and five women gave their finding after two hours of deliberation on May 23.

Following the inquest, area coroner for central and south east Kent, Katrina Hepburn, sent a Prevention of Future Deaths report to the Department for Education (DfE), which is responsible for early years education and training.

The report found it was not clear nursery staff appreciated the importance of mirroring weaning at home with weaning at nursery.

This is the process of switching a child’s diet from breast milk or formula to other foods and fluids.

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

It was also not clear nursery staff appreciated the importance of eliciting and recording this detailed information from the family and circulating it to 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 a result, the coroner felt it was not clear 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 even if training does cover this, it is not apparent any refresher training is provided to nursery staff holding these qualifications to ensure they are up to date in their knowledge.

The coroner submitted her report to the DfE, 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.

Oliver’s father, Lewis Steeper, has welcomed the findings.

He previously feared there may have been “missed opportunities” to save his son’s life.

He said: “As a family, we are pleased 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, 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 DfE and would welcome any meetings to look at better education and awareness for those who work with the youngest of children.”

Meanwhile, the Steeper family’s solicitor at law firm Leigh Day, Jill Paterson, added: “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 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 lessons are learned from the circumstances surrounding Oliver’s death to help ensure a similar tragedy does not happen again.”

The report also raised concerns over issues previously mentioned at Oli’s inquest.

These included early years childcare providers only being required to have one member of staff with a valid paediatric first aid certificate on site.

This was 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.

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.

The coroner therefore recommended regular refresher courses.

Leigh Day says the DfE now has a duty to respond to the report, with details of action taken or proposed to be taken, within 56 days.

In the 20 years between 2001 and 2021, the Office for National Statistics (ONS) recorded 40 deaths due to choking in infants (children aged less than one year) in England and Wales.