Lack of timely reporting and registration of food allergy fatalities
Department of Health and Social Care received 2 coroners' reports about this hazard between 18 Dec 2020 and 6 Apr 2023.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The Head of Incidents at the FSA informed the court that the FSA has started work on a reporting platform for allergic reactions, but needs access to information on all fatalities if it is to have effective oversight of food safety.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“The EWG AAIs made a number of other recommendations including the reinforcement of critical safety measures to patients on the use and management of AAIs.”
Stated timescale: end of May 2021
“the AAI EWG recommended in principle that AAIs should be made available in public locations for use to treat anaphylaxis in unforeseen, critical circumstances, provided suitable safeguards can be implemented to ensure effective and safe use of the AAIs.”
Stated timescale: end of May 2021
- 2 years 4 months laterIdentical hazardConfidence 0.90 · higha different coroner
“In my opinion action should be taken to consider establishing a national reporting system which includes timely reporting to local authority and FSA and maintenance of a register of fatalities and their investigations, and consideration be given to investigating the feasibility of wider access to AAIs.”
Original on judiciary.uk ↗ Repeated from the earlier report:reportingfatalitiesaccess
Department of Health and Social Care responded.Response (PDF) ↗Response (PDF) ↗
- All reports to Department of Health and Social Care
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2020 → 2023Alexandra Briess2 years 4 months after Ruben Bousquet · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight the lack of a timely national reporting system and register for allergy-related fatalities, calling for improved information sharing between local authorities, coroners and the FSA.
Ruben Bousquet · 18 Dec 2020
“The Head of Incidents at the FSA informed the court that the FSA has started work on a reporting platform for allergic reactions, but needs access to information on all fatalities if it is to have effective oversight of food safety.”
Original on judiciary.uk ↗ Alexandra Briess · 6 Apr 2023
“In my opinion action should be taken to consider establishing a national reporting system which includes timely reporting to local authority and FSA and maintenance of a register of fatalities and their investigations, and consideration be given to investigating the feasibility of wider access to AAIs.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The FSA has started work on a project designed to collect more reported data on food-based allergic reactions that do not result in death. Work on this project is progressing despite some disruption due to the COVID-19 pandemic. We are currently undertaking discovery work with people with allergies to understand the type of information they could provide and the data that the FSA could receive on allergic reactions. This will enable us to assess expectations and the perceived usefulness of such”
Stated action · timescale: end of May 2021
“The EWG AAIs made a number of other recommendations including the reinforcement of critical safety measures to patients on the use and management of AAIs.”
Stated action · timescale: end of May 2021
“the AAI EWG recommended in principle that AAIs should be made available in public locations for use to treat anaphylaxis in unforeseen, critical circumstances, provided suitable safeguards can be implemented to ensure effective and safe use of the AAIs.”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Department of Health and Social Care at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2020 → 2023 | 0.79 | 0.27 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.