James Atkinson
26 Jan 2024 · Coroner Karen Dilks · Newcastle and North Tyneside
This report repeats 1 earlier warning, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. lack of regular allergy review
“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”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“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.”
This report
“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.”
Closely relatedConfidence 0.90 · high
This report
“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.”
Later report
“[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.”
Closely relatedConfidence 0.90 · high
This report
“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.”
Later report
“The evidence at the inquest referred to allergy action plans discussed in the healthcare settings and given to parents and patients.”