Lack of public access to adrenaline auto-injectors
Department of Health and Social Care received 2 coroners' reports about this hazard between 12 May 2017 and 18 Dec 2020.
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 4 specific actions.
The story, report by report
Spacing grows with the time between reports.
“generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“I am hopeful that work underway to change the law to allow schools to hold spare auto-injectors without a named individual prescription, for use as emergency back- up to treat anaphylaxis in children registered by the school as being in receipt of a medical prescription for an auto-injector, will tackle some of the challenges which staff faced in this sad case, and which were set out in your determination.”
Stated timescale: 1 October 2017
“Implementation of the Asthma Friendly Schools Project”
- 3 years 7 months laterClosely relatedConfidence 0.90 · higha different coroner
“[the deceased]'s parents have asked that the feasibility of food businesses being issued with AAIs.”
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
- 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.
2017 → 2020Ruben Bousquet3 years 7 months after Nasar Ahmed · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight the lack of readily available adrenaline auto‑injectors in settings where rapid treatment of anaphylaxis is needed.
Nasar Ahmed · 12 May 2017
“generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.”
Original on judiciary.uk ↗ Ruben Bousquet · 18 Dec 2020
“[the deceased]'s parents have asked that the feasibility of food businesses being issued with AAIs.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We have produced a number of national guidelines using a process accredited by N JCE (National Institute of Care Excellence) and these include the following: I. BSACI Guidelines for the Management or Egg Allergy (20 I0 ) 2. BSACI Guidelines for Diagnosis and Management ofCows Milk Allergy (2014) 3. BSACI Guidelines on Adrenaline Auto-injectors (2016) 4. BSACI Guidelines on the Diagnosis and Management of ul Allergy (2017)”
Stated action · timescale: 1 October 2017
“I am hopeful that work underway to change the law to allow schools to hold spare auto-injectors without a named individual prescription, for use as emergency back- up to treat anaphylaxis in children registered by the school as being in receipt of a medical prescription for an auto-injector, will tackle some of the challenges which staff faced in this sad case, and which were set out in your determination.”
Stated action
“Implementation of the Asthma Friendly Schools Project”
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.”
- 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 |
|---|---|---|---|---|
| 2017 → 2020 | 0.75 | 0.40 | 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.