An Indian-origin schoolboy with a rare form of dairy allergy who died in the UK when his classmate flung a piece of cheese at him was not killed intentionally, an inquest into the death concluded here on Friday.

Senior Coroner Mary Hassall said the classmate who threw the cheese taken from a friend's sandwich was "simply not thinking".

"It was a childish and thoughtless act but was not calculated to cause serious harm. His fatal reaction to an allergen that was not ingested but was only ever in contact with his skin was extraordinarily rare," Hassall said at

"Karanbir's school did not have an effective system for educating its pupils in the dangers of allergies," she noted.

The asthmatic Karan was discovered "gasping for air" by paramedics at his school in Greenford on the fateful day.

He had allergies to wheat, gluten, egg, milk and tree nuts and his condition quickly worsened when he came in contact with cheese. He began scratching vigorously at his skin, the inquest heard.

"He pulled his shirt off, screamed and flung himself around the room in panic. He could not breathe," the coroner noted, as she recorded a "narrative" verdict in the case.

Karan died after 11 days in intensive care following the incident in which one boy threw some cheese at Karan, passed from a sandwich by a third boy. Both the schoolboys, also aged 13, gave evidence to the inquest hearing from behind the screen.

During three days of evidence last week, the court heard that although Karan was a "pretty typical patient" at allergy clinics, his death from anaphylactic shock brought about by skin contact was very rare and unprecedented.

"If it was skin contact alone that caused, in this case, fatal anaphylaxis, I believe that would be unprecedented," said consultant paediatrician Adam Fox in his expert witness statement.

The coroner called the school's healthcare provision for Karan "inadequate" and said a contributing factor in his death was the fact that his allergy action plan was not included in the school's care plan or medical box.

After a delay, he was administered with an EpiPen, which contained adrenaline that was a year out of date.

"It is not possible to say whether the use of adrenaline that was in date or the administration of a second EpiPen would have changed the outcome, but they would have given Karanbir a better chance of survival," Hassell said.

She called for schools in England to better educate pupils to the dangers of allergies and to better implement care plans for children with allergies.

"Karan's death has left us with a hole that will never be filled. The sorrow and sadness of losing Karan is so palpable and fresh it seems we will never be able to overcome it," said father Amarjeet Cheema, an administrator.

"He was a very, very bright young boy. He was so bright he could have been anything he wanted," said his accountant mother Rina Cheema.

A lawyer for the family said they were considering taking action against the school in light of concerns "about the part the school played in Karan's death".

Karan's death had prompted the Scotland Yard to launch a probe.

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