Hannah Jacobs: Prevention of Future Deaths Report (1)

1. 1. failure to recognise anaphylaxis

   “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 which her paediatric consultant (who gave evidence) said, with the benefit of hindsight was actually a manifestation of her inability to swallow. This is a sign of anaphylaxis This was not recognised by dental staff as an inability to swallow and thus of anaphylaxis”

2. 2. false reassurance from mild symptom classification

   “The other symptom [the deceased] demonstrated was swelling of her lips which is listed on allergy plans as a mild to moderate symptom and thus provided a false sense of reassurance to her mother that cetirizine was what she needed”

3. 3. lack of clear distinction between anaphylaxis and mild reaction

   “The risk of future deaths in the context of anaphylaxis remains in the absence of further consideration of what constitutes an anaphylactic reaction as opposed a mild reaction, and the education of parents and patients of the safety of using AAls (adrenaline auto injectors) lF lN DOUBT”

4. 4. delayed adrenaline administration due to preparation time

   “I was made aware there had been a shortage of AAI at the time but a vial of adrenaline was available at the chemist. However, it takes time to draw up. I am not sure if (assuming no national shortage) all chemists have AAI in stock for emergencies”

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