A 13-year-old girl with a severe dairy allergy died after drinking a Costa Coffee hot chocolate following a "failure to follow the processes in place to discuss allergies", an inquest has concluded.
Assistant coroner Dr Shirley Radcliffe also said there had been "failure of communication" between the coffee shop staff and Hannah Jacobs' mother.
The teenager, of Barking, east London, died within hours of taking the drink on February 8 2023, East London Coroner's Court was told.
Dr Radcliffe said: "The root cause of this death is a failure to follow the processes in place to discuss allergies combined with a failure of communication between the mother and the barista."
The coroner also noted that on the day of her death, "neither Hannah or her mother were carrying an epi-pen that had been prescribed".
A post-mortem examination found Hannah died after suffering from a hypersensitive anaphylactic reaction triggered by an ingredient in her hot chocolate that caused an allergic response.
In a statement, Hannah’s mother Abi Duyile, accused the food industry of treating allergy training as a "tick box exercise".
She said: “Hannah was just entering adolescence and learning to be independent, taking ownership of her allergies when she was tragically taken from us. She had known from a young age what her allergies were and took them very seriously.
"I have always been extremely diligent in managing Hannah’s allergies and she had never suffered a serious allergic reaction prior to this incident.
"Hannah loved life. She was a vivacious, caring, affectionate, outspoken and energetic child with a strong sense of right and wrong. Hannah had everything to live for and was so full of life and promise.
"Having heard all the evidence over the last week it is clear to me that although the food service industry and medical professionals are required to have allergy training, this training is really not taken seriously enough. And better awareness is needed in these industries and across society of the symptoms of anaphalxis.”
She added: “Allowing people who serve food and drinks to retake an allergy training test 20 times is not acceptable.
“Treating allergy training as a tick box exercise is not acceptable... And the consequence is that my daughter is no longer here. My beautiful Hannah only had 13 years on this earth when she should have had many, many more. “
The inquest previously heard that, at the time of Hannah's death, allergen training for new Costa staff involved a series of online modules that could be accessed at home, and a quiz that trainees had to pass.
During the inquest, the court heard evidence from Costa staff about their training on food safety and allergens.
The court heard written evidence from Costa employees, one of whom said they had failed the quiz 20 times before passing, and another who said their husband had accompanied them to work on their first day to help translate for them, and that they used Google Translate to help them when reading English.
Faton Abrashi, a regional operations manager for Costa Coffee stores in London, whose responsibilities include allergy procedures for staff, told the inquest on Thursday that Costa baristas were only permitted to serve customers who had said they had an allergy when ordering, if they had completed specific allergy safety training.
Mr Abrashi confirmed that, as of February 2023, there was no requirement to complete the online modules in the presence of colleagues, and they could be done at home.
He said the online training is only provided in English, with no other language options, and he, as a regional manager, would not be aware how many times a trainee had attempted the quiz before they passed.
The inquest previously heard there is a factual dispute about the order, and Ms Duyile says she asked for two soya hot chocolates and asked staff to thoroughly clean the equipment.
A Costa Coffee spokesperson said: “The loss of Hannah is a tragedy, and our heartfelt thoughts remain with her family and friends. Understanding how this awful situation occurred is in the interest of everyone – our franchise partners, our customers, our team members, and the communities of which we are a part.
“We have listened to everything the Coroner has said this week and will carefully consider her comments together with any report she may issue and respond appropriately.”
