Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of regular allergy review and named accountability for allergy services
The earlier warning
Alexandra Briess · 6 Apr 2023 · Heidi Connor, Berkshire
“The issues within this Prevention of Future Deaths report are predominantly national issues, but I heard at inquest that there is no person with named accountability for allergy services and allergy provision at NHS England, or the Department of Health as a whole.”
judiciary.uk/…/alexandra-briess-prevention-of-future-deaths-rep…
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 26 Jan 2024 · James Atkinson · Karen Dilks · Closely related · confidence 0.90 (high)
- 20 Aug 2024 · Hannah Jacobs: Prevention of Future Deaths Report (2) · Shirley Radcliffe · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · James Atkinson · 26 Jan 2024
“The evidence in this case unequivocally established that [the deceased] was not under regular review for his allergy, risk of anaphylaxis and the benefits of automatic adrenalin injectors.”
Later · Hannah Jacobs: Prevention of Future Deaths Report (2) · 20 Aug 2024
“[the deceased] was regularly prescribed Epi-pens (AAl) and had 2 at home and 2 at school. There was no consideration about how to contain the risk of anaphylaxis on the journey to and from school.”
What happened next
No web check of the stated actions has been published for this chain.