Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of timely reporting and registration of food allergy fatalities
The earlier warning
Ruben Bousquet · 18 Dec 2020 · Andrew Harris, London Inner South
“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.”
judiciary.uk/prevention-of-future-death-reports/ruben-bousquet
What was promised
Stated action 1 · response to Ruben Bousquet (18 Dec 2020) · stated 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.”
judiciary.uk/…/2020-0298-Response-from-Dept-for-Health-and-Soci…
Stated action 2 · response to Ruben Bousquet (18 Dec 2020) · 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.”
What recurred
- 6 Apr 2023 · Alexandra Briess · Heidi Connor · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · 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.”
What happened next
No web check of the stated actions has been published for this chain.