Natasha Ednan-Laperouse
8 Oct 2018 · Coroner Sean Cummings · London (West)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. inadequate allergen labelling on pre-packed food
“That allergens were not labelled adequately or clearly on Pret-a-Manger packaging when prepared in their kitchens”
2. lack of coordinated allergic reaction monitoring
“In the case of Pret-a-manger there was no coherent or co-ordinated system for monitoring customer allergic reactions despite sales of more than 200 million items”
3. inadequate needle length in adrenaline autoinjectors
“In the Emergency treatment of anaphylactic reactions Guidelines for healthcare providers the preferred needle length is 25 mm for adrenaline injectors to access muscle in most people”
4. inadequate adrenaline dose in autoinjectors
“The dose of adrenaline in Epipen is 300mcg. The UK Resuscitation Council recommends a standard emergency dose of 500mcg”
Linked reports
Identical hazardConfidence 0.95 · high
This report
“The dose of adrenaline in Epipen is 300mcg. The UK Resuscitation Council recommends a standard emergency dose of 500mcg.”
Later report
“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.”
Responses
2018-0279-Response-by-Department-for-Environment-Food-Rural-Affairs.pdf ↗· Department for Environment
2018-0279-Response-by-MHRA.pdf ↗· Food and Rural Affairs
Stated action
“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”