Inadequate adrenaline dose in autoinjectors
Medicines and Healthcare products Regulatory Agency received 2 coroners' reports about this hazard between 8 Oct 2018 and 27 Jan 2020.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 3 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The dose of adrenaline in Epipen is 300mcg. The UK Resuscitation Council recommends a standard emergency dose of 500mcg.”
Original on judiciary.uk ↗ Medicines and Healthcare products Regulatory Agency responded, stating 1 specific action.Response (PDF) ↗
“manufacturers were required to disclose the exposed needle length of their adrenaline auto-injector devices in the product information to inform the healthcare professional and patient so they can take this in to account in deciding which device is appropriate for an individual patient”
- 1 year 4 months laterIdentical hazardConfidence 0.95 · higha different coroner
“When [name redacted]'s AAI was changed from an EpiPen to an Emerade, her GPs failed to reconsider the prescription and to increase her dose from 300mgs to 500mcgs.”
Original on judiciary.uk ↗ Repeated from the earlier report:EpiPendose
Medicines and Healthcare products Regulatory Agency responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“Following Ms [name redacted] death, the Practice undertook an audit in October 2019 of all patients who were being prescribed Emerade to ensure that the dosage was in accordance with the BNF based on the respective patients' weight and age. Indeed, all patients who use AAI pens have had their doses reviewed. Patients have been contacted to ensure that they have the correct dose and appropriate knowledge about the use and storage of the pen. Letters were sent to patients on Emerade, which included”
Stated timescale: October 2019
“we will consider how best to make clear In CG134 the advice that 2 adrenaline auto-injectors should be prescribed, which patients should carry at 811 tfflls.”
- All reports to Medicines and Healthcare products Regulatory Agency
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2018 → 2020Shanté Turay-Thomas1 year 4 months after Natasha Ednan-Laperouse · different coronerIdentical hazardConfidence 0.95 · high
Identical hazardConfidence 0.95 · highBoth reports highlight that the adrenaline dose delivered by the prescribed auto‑injector (300 µg) is below the recommended emergency dose of 500 µg, creating a risk of inadequate treatment for anaphylaxis.
Natasha Ednan-Laperouse · 8 Oct 2018
“The dose of adrenaline in Epipen is 300mcg. The UK Resuscitation Council recommends a standard emergency dose of 500mcg.”
Original on judiciary.uk ↗ Shanté Turay-Thomas · 27 Jan 2020
“When [name redacted]'s AAI was changed from an EpiPen to an Emerade, her GPs failed to reconsider the prescription and to increase her dose from 300mgs to 500mcgs.”
Original on judiciary.uk ↗
Stated action
“manufacturers were required to disclose the exposed needle length of their adrenaline auto-injector devices in the product information to inform the healthcare professional and patient so they can take this in to account in deciding which device is appropriate for an individual patient”
Stated action · timescale: October 2019
“Following Ms [name redacted] death, the Practice undertook an audit in October 2019 of all patients who were being prescribed Emerade to ensure that the dosage was in accordance with the BNF based on the respective patients' weight and age. Indeed, all patients who use AAI pens have had their doses reviewed. Patients have been contacted to ensure that they have the correct dose and appropriate knowledge about the use and storage of the pen. Letters were sent to patients on Emerade, which included”
Stated action
“we will consider how best to make clear In CG134 the advice that 2 adrenaline auto-injectors should be prescribed, which patients should carry at 811 tfflls.”
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Medicines and Healthcare products Regulatory Agency at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2018 → 2020 | 0.64 | 0.17 | Identical · 0.95 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.