Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate adrenaline dose in autoinjectors
The earlier warning
Natasha Ednan-Laperouse · 8 Oct 2018 · Sean Cummings, London (West)
“The dose of adrenaline in Epipen is 300mcg. The UK Resuscitation Council recommends a standard emergency dose of 500mcg.”
What was promised
Stated action 1 · response to Natasha Ednan-Laperouse (8 Oct 2018) · stated timescale: none stated
“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”
What recurred
- 27 Jan 2020 · Shanté Turay-Thomas · Mary Hassell · Identical hazard · confidence 0.95 (high)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · 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.”
What happened next
No web check of the stated actions has been published for this chain.