Owen Carey
30 Sept 2019 · Coroner Briony Ballard · London Inner (South)
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. human error in allergen handling
“there must have been a human error by a member of Byron 02 serving staff at the point of ordering”
2. lack of allergen information on menu
“The menu was reassuring in that it made no reference to any marinade or any potential allergenic ingredient in the food selected”
3. inadequate allergen notice visibility
“the prompt for this discussion on the Byron 02 menu at the time was: (i) on the side of the menu which appeared to focus solely on a 'special', namely a [name redacted] burger, (ii) at the very bottom and distant from all the main food options, (iii) in very small font and (iv) on a royal blue background in black ink”
4. absence of regulatory standards for allergen notices
“there are no statutory requirements regarding the appearance of such an allergy notice”
5. missing allergen symbols on menus
“the absence of any simple allergen words or symbols on the face of a restaurant menu is of concem”
6. absence of national anaphylaxis death register
“there is therefore no national register recording the circumstances of these deaths which could then be analysed and learnt from by allergy specialists”
Linked reports
Identical hazardConfidence 0.96 · high
This report
“there is therefore no national register recording the circumstances of these deaths which could then be analysed and learnt from by allergy specialists”
Later report
“It would welcome improved appropriate sharing of information on fatalities as they are not routinely notified in a timely manner when there is a report of a fatality by the local authority or coroner.”
Closely relatedConfidence 0.80 · moderate
This report
“there is therefore no national register recording the circumstances of these deaths which could then be analysed and learnt from by allergy specialists”
Later report
“Gathering data and using this to research and reduce the risk of future deaths requires funding, and this should be reviewed.”
Responses
2019-0335-Joint-response-from-FSA-DEFRA-and-DHSC-Redacted.pdf ↗· Department for Environment
Stated action · early 2020
“The FSA will be hosting an Allergy Symposium in”
2019-0335-Response-by-BSACI.pdf ↗· National Trading Standards Board
Stated action
“The BSACTI believes that there is a need for 2 distinct registries. The first is a national register for all anaphylactic reactions, that can be contributed to by any health care professional and would provide invaluable data on emerging patterns of reactions and their circumstances and effectively operate as an early warning signal for new risks and highlight specific situations where risk is higher so that they can be actively mitigated. Such a registry already exists in Europe and the Food St”
2019-0335-Response-by-Byron.pdf ↗· Byron Hamburgers
2019-0335-Response-by-National-Trading-Standards.pdf ↗· National Trading Standards Board