Inconsistent allergy action plans fail to communicate anaphylaxis symptoms
British Society for Allergy and Clinical Immunology received 2 coroners' reports about this hazard between 10 May 2019 and 20 Aug 2024.
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 0 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Allergy action plans are not standardised across hospitals and schools, so messages are not as clearly delivered as they could be.”
Original on judiciary.uk ↗ British Society for Allergy and Clinical Immunology responded.Response (PDF) ↗Response (PDF) ↗
- 5 years 3 months later
Raised again · 1st time
Hannah Jacobs: Prevention of Future Deaths Report (1)↗
20 Aug 2024 · Shirley Radcliffe · East London
Closely relatedConfidence 0.80 · moderatea different coroner“The evidence at the inquest referred to allergy action plans discussed in the healthcare settings and given to parents and patients. [the deceased] displayed what appeared to be excessive salivation at the dentist”
Original on judiciary.uk ↗ Repeated from the earlier report:allergyactionplans
British Society for Allergy and Clinical Immunology responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to British Society for Allergy and Clinical Immunology
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.
2019 → 2024Hannah Jacobs: Prevention of Future Deaths Report (1)5 years 3 months after Karanbir Cheema · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports involve allergy action plans and their effectiveness in communicating critical information. The earlier report highlights lack of standardization, while the later notes that even when plans exist, symptoms may be missed.
Karanbir Cheema · 10 May 2019
“Allergy action plans are not standardised across hospitals and schools, so messages are not as clearly delivered as they could be.”
Original on judiciary.uk ↗ Hannah Jacobs: Prevention of Future Deaths Report (1) · 20 Aug 2024
“The evidence at the inquest referred to allergy action plans discussed in the healthcare settings and given to parents and patients. [the deceased] displayed what appeared to be excessive salivation at the dentist”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- 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 British Society for Allergy and Clinical Immunology 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 |
|---|---|---|---|---|
| 2019 → 2024 | 0.60 | 0.15 | Closely related · 0.80 | 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.