Ruben Bousquet
18 Dec 2020 · Coroner Andrew Harris · London Inner South
This report repeats 2 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of timely reporting and registration of food allergy fatalities
“Reporting and Registering”
2. absence of emergency adrenaline auto-injectors in food businesses
“Availability of emergency Adrenaline Auto-injector devices (AAIs) in the Retail food sector”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.”
This report
“[the deceased]'s parents have asked that the feasibility of food businesses being issued with AAIs.”
Identical hazardConfidence 0.96 · high
Earlier report
“there is therefore no national register recording the circumstances of these deaths which could then be analysed and learnt from by allergy specialists”
This report
“It would welcome improved appropriate sharing of information on fatalities as they are not routinely notified in a timely manner when there is a report of a fatality by the local authority or coroner.”
Identical hazardConfidence 0.90 · high
This report
“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 report
“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.”
Responses
2020-0298-Response-from-Dept-for-Health-and-Social-Care-Redacted.pdf ↗· Department of Health and Social Care
Stated action · 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.”
2020-0298-Response-from-Food-Standards-Agency-Redacted.pdf ↗· Food Standards Agency
Stated action · end of next year
“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”
2020-0298-Response-from-MHRA-Redacted.pdf ↗· Communities and Local Government
Stated action · 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.”