Coroner calls for UK anaphylaxis register after Pret a Manger deaths

The families of two Pret a Manger customers who died after experiencing severe allergic reactions have welcomed a report from a senior coroner suggesting hospitals should be obliged to report fatal and near-fatal anaphylaxis.

Maria Voisin, the senior coroner for Avon, said a robust system of capturing and recording serious cases of anaphylaxis could provide an early warning of the risk posed to allergic individual byproducts with an undeclared allergen content.

She said the system could involve mandatory reporting by hospitals to local health protection officials of anaphylaxis similar to the current system for notifiable diseases.

Voisin sent her recommendations in a prevention of future deaths report to bodies including the UK health department and the Food Standards Agency (FSA) after the case of Celia Marsh, a Wiltshire dental nurse with a severe dairy allergy who died after eating a “vegan” Pret a Manger wrap contaminated with milk protein.

She also called for more “robust” labelling and testing systems, warning: “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.

“Examples include ‘free-from’ and ‘vegan’. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.”

Marsh’s family said: “We welcome the prevention of future deaths report as the next step in our fight to make the world a safe place for allergy sufferers like our beloved mum and wife.

“Above all, we hope that the FSA, UK Health Security Agency and the Department of Health and Social Care will now start working together to put in place a system for mandatory reporting of fatal and near-fatal anaphylactic reactions to allow the public to be alerted of unsafe allergen products and provide an accurate record of such incidents. This will ensure important lessons can be learned with the appropriate enforcement action being taken.”

Tanya Ednan-Laperouse, whose 15-year-old daughter, Natasha, died in 2016 after eating a Pret baguette containing sesame seeds, said: “The coroner’s clear and concise recommendations should herald a transformation of the way anaphylaxis cases are dealt with in this country and mean that Celia’s death was not in vain.

“We are particularly pleased to see that the coroner has called for anaphylaxis to be considered a notifiable disease with a national register of fatal and near-fatal cases of severe food allergic reactions.

“She has also called for a thorough overhaul of potentially misleading and dangerous precautionary allergen labelling and the implementation of robust allergen testing by food producers. These well-overdue measures will save lives.”