Lack of regular allergy review and named accountability for allergy services
Department of Health and Social Care received 3 coroners' reports about this hazard between 6 Apr 2023 and 20 Aug 2024.
They came from 3 different coroners in 3 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 0 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The issues within this Prevention of Future Deaths report are predominantly national issues, but I heard at inquest that there is no person with named accountability for allergy services and allergy provision at NHS England, or the Department of Health as a whole.”
Original on judiciary.uk ↗ Department of Health and Social Care responded.Response (PDF) ↗Response (PDF) ↗
- 10 months laterClosely relatedConfidence 0.90 · higha different coroner
“The evidence in this case unequivocally established that [the deceased] was not under regular review for his allergy, risk of anaphylaxis and the benefits of automatic adrenalin injectors.”
Original on judiciary.uk ↗ Department of Health and Social Care responded.Response (PDF) ↗Response (PDF) ↗
- 7 months later
Raised again · 2nd time
Hannah Jacobs: Prevention of Future Deaths Report (2)↗
20 Aug 2024 · Shirley Radcliffe · East London
Closely relatedConfidence 0.90 · higha different coroner“[the deceased] was regularly prescribed Epi-pens (AAl) and had 2 at home and 2 at school. There was no consideration about how to contain the risk of anaphylaxis on the journey to and from school.”
Original on judiciary.uk ↗ Repeated from the earlier report:riskanaphylaxis
Department of Health and Social Care responded.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.
2023 → 2024James Atkinson10 months after Alexandra Briess · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight a gap in organised responsibility for allergy services within the health system. The earlier report notes the absence of a named accountable person, while the later report points to missing structures for regular review and management of allergy risk.
Alexandra Briess · 6 Apr 2023
“The issues within this Prevention of Future Deaths report are predominantly national issues, but I heard at inquest that there is no person with named accountability for allergy services and allergy provision at NHS England, or the Department of Health as a whole.”
Original on judiciary.uk ↗ James Atkinson · 26 Jan 2024
“The evidence in this case unequivocally established that [the deceased] was not under regular review for his allergy, risk of anaphylaxis and the benefits of automatic adrenalin injectors.”
Original on judiciary.uk ↗ 2024 → 2024Hannah Jacobs: Prevention of Future Deaths Report (2)7 months after James Atkinson · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight a gap in systematic education and review processes that leads to inadequate availability or use of adrenaline auto‑injectors for anaphylaxis risk.
James Atkinson · 26 Jan 2024
“The evidence in this case unequivocally established that [the deceased] was not under regular review for his allergy, risk of anaphylaxis and the benefits of automatic adrenalin injectors.”
Original on judiciary.uk ↗ Hannah Jacobs: Prevention of Future Deaths Report (2) · 20 Aug 2024
“[the deceased] was regularly prescribed Epi-pens (AAl) and had 2 at home and 2 at school. There was no consideration about how to contain the risk of anaphylaxis on the journey to and from school.”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
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 |
|---|---|---|---|---|
| 2023 → 2024 | 0.61 | 0.17 | Closely related · 0.90 | different |
| 2024 → 2024 | 0.71 | 0.13 | Closely related · 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.