Not allowing children’s lives to be endangered through the provision of food they can easily choke on in early childhood education is a necessary and much welcomed change”, said child development expert Dr Sarah Alexander.
Twelve years ago, a 14-month-old child choked on hard apple during morning tea at a Te Awamutu centre and died six days later after life support was turned off. His mother lobbied the Ministry of Education and it promised it would change the rules so children would not be given dangerous food without having the texture altered (e.g., by boiling, mashing, or grating first).
Dr Alexander who is the chief executive of ChildForum, said that the Ministry of Education never followed through on its promise to the Te Awamutu family, and in almost the same circumstances another very young child almost lost his life.
Dr Alexander investigated and subsequently reported the case of a 22-month-old child who choked on raw apple at a centre in Rotorua in 2016. (A copy can be found here).
Her report led to a Sunday TVNZ documentary that screened on 31 March 2019, which the Ministry of Education declined to appear on. News of the case was reported in many countries internationally.
Today (8 December) the Ministry of Education announced some changes to the criteria it uses to assess service compliance with health and safety standards under the Education (ECE Services) Regulations to meet 1.5 recommendations of the 7 recommendations made in the report of the 2016 tragic incident.
From the 25th January 2021 all ECE services must follow Ministry of Health advice on reducing the chance of food-related choking (the advice can be found here). Where parents provide food, services will be required to promote best practices as set out in the health advice and provide parents with a copy of the advice. Services must also ensure that children are seated while eating.
Until now the Ministry of Education has only required that children are supervised while eating and has allowed food that is too dangerous for an infant or young child to eat to be given to children.
Dr Alexander believes that the Ministry of Education should have fronted the media on the 2016 Rotorua choking case and should have accepted responsibility to put child safety first and implement positive changes sooner.
“It has taken far too long for the Ministry of Education to make this change. It has taken a huge amount of prodding and work on the part of the Rotorua child’s family and myself to get the Ministry to do what it should have done years ago”, she said.
The Ministry of Health states that the advice for ECE services must be more prescriptive than the common-sense advice given to parents, because a close relationship with children and degree of supervision is not often possible in centres as it is in homes.
The Early Childhood Council, a private industry lobby group focused more on outcomes for financial profit than on positive outcomes for children, opposed changes. The industry group represents the service provider (Evolve Education) that owns the Rotorua centre where the 22-month-old nearly lost his life after choking. The group's paid spokesperson Peter Reynolds told the media that disallowing the feeding of high choking foods was “over the top”.
“We don’t want to wrap these kids in cotton wool, that’s not going to do them any favours,” Mr Reynolds said (Stuff, 31/10/2019).
But Dr Alexander praised the Ministry of Education: “credit is due to the Ministry of Education for finally moving to make it clear that any service that potentially endangers a child's life by giving food that does not meet the Ministry of Health advice will be breaching regulations. This should help to make ECE safer for children.”
However, she warned that the current high trust model the Ministry has with services regarding compliance meant that services which chose to cut corners to save on the cost of food or food preparation, or because they think they know better, could continue to do so.
“Because monitoring of services by the Ministry of Education is irregular and inadequate, it is not going to know if a service is meeting the new requirement unless a child who chokes is admitted to hospital. If all choking events requiring first aid were reportable then we would have a much better picture of the level of compliance,” she said.
Another positive change is requiring more adults in a service to hold a current First Aid certificate (currently 1 adult to every 50 children and this will change to 1 adult to every 25 children).
But the change falls short on what’s needed to improve safety in two respects.
First, there is no requirement on service providers to check that staff can correctly demonstrate the first aid that is required for an infant and for a young child who is choking.
“We learnt from the 2016 serious choking incident at a Rotorua centre that if the first aid trained adults can’t perform the correct first aid for an infant choking then being first aid qualified makes no difference to outcomes,” said Dr Alexander
Second, the Ministry of Education has not specified that first aid qualified adults will need to be present in every classroom. This is a problem, because in large centres children may still have no first aid qualified person present in their room.
“The Ministry of Education’s public relations mantra is that ‘nothing is more important than the safety and well-being of children’. At long last it is showing that it intends to better live up to its mantra and is moving toward make eating in early childhood services safer.”
Four years and 6 months ago, a 22-month-old child choked on the apple he was provided to eat for afternoon tea, at a publicly-funded licensed and regulated early childhood centre in Rotorua. He very nearly died. The toddler had a cardiac arrest for 30 minutes and sustained a hypoxic brain injury that has left him severely and permanently disabled.
Child development expert and CEO of ChildForum Dr Sarah Alexander worked on a report on the 2016 tragic incident after being approached by the toddler’s parents.
Dr Alexander found that there had very likely been serious breaches in the Education (Early Childhood Services) Regulations. The regulations require providers of early childhood services to take all reasonable steps to promote the good health and safety of children and to take all reasonable precautions to prevent accidents among children (Regulation 46, 1a & b).
However, the Ministry of Education's view was that the centre did not breach the regulation to take all reasonable steps to promote the good health and safety of the 22 month old child who choked on raw apple he was given to eat. Yet health experts (and Plunket!) advocate against giving such a high risk food to young children without first grating or boiling the apple to reduce the risk of choking – so the service provider certainly did not take all reasonable steps to promote the health and safety of the child or protect the child from harm.
Worksafe did not consider Regulation 46, 1a and b. It's view was that the centre was fully compliant with the criteria that the Ministry of Education uses to assess compliance with the Regulations. The only mistake the centre made according to Worksafe was giving raw apple to very young children.
In April 2019 Dr Alexander contacted the Secretary for Education Iona Holsted and requested a meeting so she could hear the concerns of the toddler’s parents.
Prior to the meeting the Deputy Secretary for Education Sean Teddy forwarded a copy of Dr Alexander’s report to the Director General of Health, Dr Ashley Bloomfield.
Dr Bloomfield replied to the Ministry of Education: “Thanks to Sean for the letter and the copy of Sarah's report, which I have read. I have also noted the letter from the Secretary of Education to Dr Alexander, and can confirm that the relevant Ministry of Health guidelines are clear on the need to avoid raw apple (and a range of other foods) in toddlers and pre-schoolers due to the choking risk.”
The child’s family and Dr Alexander believed that the incident was avoidable. It would not have happened had raw apple not been given.
The Ministry of Education did not investigate the centre. It did not speak to the child’s parents and it did not inform them of their right to make a complaint. It focused on aiding the centre to quickly get back to running as normal as if nothing had happened.
Neither the centre nor the Ministry of Education as the regulatory body has been held accountable for what happened.
On 7 October 2019 Dr Alexander wrote a strongly worded opinion piece about deficiencies on the part of the Ministry of Education to ensure child safety and called for an external review.
On 22 October 2019 the Ministry of Education announced it would start public consultation on proposed changes to the criteria it uses for checking on service compliance with the regulations, so services would be required to follow Ministry of Health guidelines on how to minimise the risk of children choking on food.
Public consultation closed on 15 November 2019. It has taken a year since then for the Ministry of Education to announce changes to its licensing criteria.
The report into the 2016 serious incident made 7 recommendations. The changes announced by the Ministry of Education will met recommendation 1 and part of recommendation 2. Other recommendations have yet to be met.
- For the avoidance of any doubt and to make it very clear that high-risk food should not be given to children the Ministry of Education without any further delay must add the following requirement into its licensing criteria:” no child is to be provided food known to be a high risk for choking where the texture has not been altered to reduce risk, according to Ministry of Health guidelines for food safety.”
- The first aid training requirements must be reviewed. Changes recommended are that: (a) all staff who are counted as first aid qualified in a centre must be able to correctly demonstrate in practice the recommended first-aid for an infant and a young child who is choking, and (b) more than the 1 teacher currently per 50 children should be required to hold a recognised first aid qualification especially in case of a serious incident that may require at least two adults to be involved in administering first aid, and in each classroom within a centre there should be at least one or more adults who are first-aid qualified.
- Following every serious incident involving hospitalisation or death the Ministry of Education must carry out a full licensing inspection of the early childhood service. It should not be left to grieving family members or others to make a complaint against a service before the Ministry undertakes a compliance inspection.
- The Ministry of Education must take steps to communicate with families following a serious incident, demonstrate an ethic of care to the child and family, and show it expects the same of service providers.
- When a serious incident involving a child occurs the Ministry of Education must act to properly investigate and make its report publicly available. The report must include details on the actions and factors that led to the incident and what can be learned to reduce the chance of something similar happening again, thereby improving safety.
- Better public education on foods that are high risk for choking and what adults and early childhood services can do to prevent food-related choking is something that the Ministry of Education needs to work with the Ministry of Health on.
- And finally, in the early childhood sector we really need to see the Ministry of Education accepting responsibility along with it learning to be more open and transparent in its response to serious incidents.
A copy of the report and related materials can be found here: Choking on raw apple: A report into a tragic incident in NZ early childhood education