Alexandra Briess
6 Apr 2023 · Coroner Heidi Connor · Berkshire
This report repeats 2 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of named accountability for allergy services and allergy provision
“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”
2. absence of national reporting system for anaphylaxis
“In my opinion action should be taken to consider establishing a national reporting system which includes timely reporting to local authority and FSA and maintenance of a register of fatalities and their investigations, and consideration be given to investigating the feasibility of wider access to AAIs”
3. inadequate mandatory reporting of anaphylaxis cases
“To establish a robust system of capturing and recording cases of anaphylaxes, and specifically, fatal and near-fatal anaphylaxis... · Such a system could involve, mandatory reporting of anaphylaxis presenting to hospital analogous to the current system for notifiable diseases... by registered medical practitioners have a statutory duty to notify the 'proper officer' at their local council or local health protection team of suspected cases of certain infectious diseases”
4. insufficient funding for national anaphylaxis data collection and research
“Gathering data and using this to research and reduce the risk of future deaths requires funding, and this should be reviewed”
5. missing integration of UKFAR referral in resuscitation protocols
“Consideration of including contact details for the UKFAR in algorithms used by doctors attempting to resuscitate patients - so that there is a clear requirement for referral to UKFAR in the event of an unsuccessful resuscitation”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“there is therefore no national register recording the circumstances of these deaths which could then be analysed and learnt from by allergy specialists”
This report
“Gathering data and using this to research and reduce the risk of future deaths requires funding, and this should be reviewed.”
Identical hazardConfidence 0.90 · high
Earlier report
“The Head of Incidents at the FSA informed the court that the FSA has started work on a reporting platform for allergic reactions, but needs access to information on all fatalities if it is to have effective oversight of food safety.”
This report
“In my opinion action should be taken to consider establishing a national reporting system which includes timely reporting to local authority and FSA and maintenance of a register of fatalities and their investigations, and consideration be given to investigating the feasibility of wider access to AAIs.”
Closely relatedConfidence 0.90 · high
This report
“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.”
Later report
“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.”