The family of a mum who died after eating a Pret wrap that was supposed to be dairy free has backed calls for widespread action to prevent further anaphylactic deaths.
Celia Marsh, 42, had an allergic reaction to a vegan rainbow wrap which contained yoghurt at a branch of Pret a Manger in Bath, Somerset, in December 2017.
The dental nurse, from Wiltshire, was out having a meal with family when she suffered a fatal anaphylactic reaction.
The £3.75 snack contained a dairy-free yoghurt, which was later found to contain traces of milk protein.
An inquest held earlier this year heard how the product was supplied by Planet Coconut, a firm set up by 'mumprenaur' Bethany Eaton.
The former cop bought the licence to market and distribute COYO in the UK from its Australian founder Henry Gosling - and built it a multi-million pound business.
But the inquest heard she admitted not carrying out any testing of the raw product, which was made in a UK Tate & Lyle factory, after relying on "assurances" from Mr Gosling it was dairy free.
Senior coroner Maria Voisin gave a narrative verdict conclusion and said lessons must be learnt to prevent future deaths.
She has now published her Prevention of Future Deaths report, making a number of recommendations that have been welcomed by Celia's family.
They include a suggestion to introduce a system for mandatory reporting of near fatal and fatal anaphylactic reactions of individuals attending hospital - similar to the current system used for notifiable diseases.
Under such a system registered medical practitioners would have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team.
This would hope to see cases dealt with promptly to avoid other families losing loved ones.
After the publication of the report, Celia Marsh's family renewed their own calls for the recommendation to be implemented with mandatory reporting of near fatal and fatal anaphylactic reactions as a notifiable disease.
They said they believe a robust system should be established to record cases of anaphylaxis which would provide vital early warnings of the potential risks posed to allergic individuals by products with undeclared allergens.
The family said in a statement: "We welcome the Prevention of Future Deaths report as the next step in our fight to make the world a safe place for allergy sufferers like our beloved mum and wife.
“Above all, we hope that the Food Standards Agency, UK Health Security Agency and the Department of Health and Social Care will now start working together to put in place a system for mandatory reporting of fatal and near fatal anaphylactic reactions to allow the public to be alerted of unsafe allergen products and provide an accurate record of such incidents.
"This will ensure important lessons can be learned with the appropriate enforcement action being taken.
“The coroner has required responses from a wider range of organisations and we very much hope that those organisations consider and take action on these suggestions as soon as possible.”
Celia’s family has also welcomed the inclusion of a wider group of recipients for the PFD report, who are required to provide responses which will detail what action they have taken in relation to the concerns raised.
At the inquest conclusion the coroner indicated she would be addressing the PFD report to the Food Standards Agency and the Royal College of Pathologists.
The published report is also addressed to the UK Health Security Agency, the British Society for Allergy and Clinical Immunology, British Retail Consortium, Food and Drink Federation, British Hospitality and the Department of Health and Social Care.
In compiling the report, the coroner incorporated suggestions made by experts and others during the inquest.
Other key suggestions include updating the Pathologists Guidance to ensure that samples are taken swiftly and preserved. This would have been key in in determining the level of milk protein that Celia had ingested prior to her death.
It was also recommended appropriate advice is given to individuals by medical professionals that will ensure allergies are effectively managed, that individuals are aware of the dangers of inadvertent exposure and that there is no safe level of an allergen that can be present in a product for those with the most serious allergies.
Labelling of allergens can potentially be misleading for example, “free from” or “vegan”.
The coroner also said products labelled as “free from” should mean just that and be completely free from that allergen.
She said there should be a "robust system" when making such a claim to confirm the absence of the relevant allergen in all the ingredients used during production and the final product.
The report also outlined that the Food Standards Agency should provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system would address this need.
The report was also welcomed by Tanya Ednan-Laperouse, whose daughter Natasha died aged 15 in 2016 after eating an unlabelled Pret baguette.
She had been supporting the Marsh family at the inquest.
Ms Ednan-Laperouse OBE, who is co-founder of the Natasha Allergy Research Foundation, said: "Nothing will ever bring Celia back and the grief endured by her family will always remain.
"But the coroner's clear and concise recommendations should herald a transformation of the way anaphylaxis cases are dealt with in this country and mean that Celia's death was not in vain.
"We are particularly pleased to see that the coroner has called for anaphylaxis to be considered a notifiable disease with a national register of fatal and near fatal cases of severe food allergic reactions.
"She has also called for a thorough overhaul of potentially misleading and dangerous precautionary allergen labelling; and the implementation of robust allergen testing by food producers. These well overdue measures will save lives.
"We also strongly welcome the recommendations for pathologists to prioritise cases where anaphylaxis is suspected as the cause of death.
"From personal experience, and the experience of others, the abject failures within the post-mortem system can deny justice to far too many families, and put others at risk by failing to raise the alarm about contaminated or wrongly-labelled products."
Michelle Victor, partner at law firm Leigh Day, which has support the Marsh family added: "We welcome the coroner’s comprehensive Prevention of Future Deaths report.
"It is crucial that all those receiving the report act on it as soon as possible to make sure that allergy sufferers can be confident that the products they eat are safe, and to make sure that any serious and fatal incidents of anaphylaxis are properly and thoroughly recorded and investigated.
"We look forward to the responses in the New Year.”
