Celia Marsh
This report repeats 2 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. inadequate death investigation process
“During the course of the inquest the evidence from a number of experts revealed matters giving rise to a concern”
2. insufficient education on food allergy risks
“I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths”
3. inadequate post mortem sampling
“The post mortem examination should be prioritised. - At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken”
4. misunderstanding of fatal allergy risk
“To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk”
5. misleading free-from labelling
“The wording used on food products, and the public's understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading”
Linked reports
Earlier report
“Evidence was given that there are no procedures in place for such communications between the health services and Trading Standards in cases of non fatal anaphylactic reactions.”
This report
“- To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.”
Earlier report
“The quality of the post mortem examination report produced i was wholly unsatisfactory and proven inaccurate.”
This report
“- If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing”
This report
“- If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing”
Later report
“a. blood samples for mast cell tryptase and sp IgE serology 2 suspected allergens b. stomach contents to be immediately stored (and/or frozen) by the pathologist for the analysis of the presence of the triggering allergen”
Responses
2022-0379-Response-from-British-Retail-Consortium.pdf ↗· The British Retail Consortium
2022-0379-Response-from-British-Society-for-Allergy-and-Clinical-Immunology.pdf ↗· British Society for Allergy and Clinical Immunology
Stated action
“We will address the points in your report which we feel are in our remit to act upon and where actions fall out of our remit, we have made suggestions.”
2022-0379-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action
“The Department of Health and Social Care notes the recommendation and concurs that it is essential we learn from tragedies such as Ms [name redacted]. Data regarding all anaphylaxis- related deaths in England and Wales are documented by the Office for National Statistics”
2022-0379-Response-from-Food-and-Drink-Federation-.pdf ↗· Food and Drink Federation
2022-0379-Response-from-Food-Standards-Agency-.pdf ↗· Food Standards Agency
2022-0379-Response-from-Royal-College-of-Pathologists.pdf ↗· Royal College of Pathologists
Stated action
“The Royal College of Pathologists is currently updating its autopsy practice guidelines for suspected acute anaphylaxis. The updated guidelines will include contact details for the UKFAR and direct pathologists to report fatal anaphylaxis cases to the UKFAR.”
2022-0379-Response-from-UK-Hospitality.pdf ↗· British Hospitality
2022-0379-Response-UK-Health-Security-Agency-.pdf ↗· UK Health Security Agency