A woman with a severe allergy died after eating a Pret a Manger vegan wrap contaminated with milk she had thought was dairy-free, an inquest has concluded.
Celia Marsh, 42, died on December 27, 2017 after eating a super-veg rainbow flatbread from the chain's store in Bath, Somerset which had traces of milk protein in it despite being labelled as dairy free.
Shoppers were shockingly seen climbing over the mum-of-five as she lay dying in the street while having the allergic reaction.
The coconut yoghurt used as dressing from the Australian brand CoYo, which was licenced for manufacture in the UK to British firm Planet Coconut, contained the traces of milk protein, senior coroner Maria Voisin concluded.
During her conclusion, the coroner said Celia died from anaphylaxis, triggered by the milk protein in the wrap she had bought from Pret and eaten roughly 15 minutes before.
She said the milk protein was found to be in the coconut yoghurt, which was made with HG1 starch and supplied by Tate & Lyle. She said this starch was made in a factory that manufactures dairy products and therefore may have contained traces of milk.
However, the yoghurt was labelled dairy-free and the risk of milk traces was not communicated to Pret.
Ms Voisin said: "Celia Marsh was allergic to milk. She died when she suffered anaphylaxis caused by consumption of a wrap contaminated with milk protein.
"The manufacturer of the dairy-free yoghurt had in its possession documentation that flagged this risk but this risk was not passed on to its customers."
Speaking after the conclusion of the inquest, Pret a Manger chief executive Pano Christou said that as a father and a husband, he could "only imagine" how distressing the ordeal had been for Celia's family.
"We fully support the coroner's findings. As the coroner made clear, Planet Coconut had information which should have alerted them that their Coyo yoghurt may have contained milk and this information was not passed on to Pret," he said.
"It goes without saying that if Pret had ever known that the Coyo yoghurt may have contained milk, we would have never used the ingredient."
Mr Christou said Pret had taken steps forward with their suppliers and labelling policies since 2017 and had in place an "allergy plan" with a commitment to lead the industry in developing new policies for people with food allergies.
The inquest at Avon Coroner's Court heard the mother-of-five avoided all dairy products following a near-fatal allergic reaction a few months earlier in which she needed 15 shots of adrenalin.
Mrs Marsh, a dental nurse from Melksham, Wiltshire, had been on a post-Christmas shopping trip with her husband and three of her daughters when she went into Pret to buy something to eat at around 2pm.
In his statement, which was read to the hearing by the coroner's officer, her husband Andy Marsh said his wife had begun to feel "a bit funny" after eating the wrap, while they were in clothing store Gap, and they decided to leave the shop.
He said: "We started walking down the narrow side street by the Gap store and Celia had her asthma inhaler out. She used it a couple of times and I asked her if she was OK.
"She said she was struggling to breathe but it may be because of the cold air. We then moved to a small side street on the left and I pulled her to one side."
He said Mrs Marsh had initially thought she was "being silly" because the sandwich had been labelled "vegan".
"She had her Epipen in her hand and I said to her that if she thought there was any chance she was having a reaction that she should just do it and use the pen as it doesn't matter," he said. "She then said to me 'You need to phone an ambulance'," he added.
Mr Marsh said he phoned 999, by which time his wife had collapsed and was being tended to by an off-duty GP who had offered to help.
Mrs Marsh was rushed to hospital in an ambulance shortly after and died that afternoon.
Speaking after the verdict, Celia's husband Mr Marsh described his wife as his "best friend" who he said could brighten your worst days with "just one smile".
"People could tell we were in love by just sitting in the same room as us and us not saying a word to each other," he said.
Mr Marsh called for tighter testing to be established and the onus to be on any manufacturer that labelled a product "free from" to take responsibility for the testing.
"I want to see testing at every stage of the process to make sure nothing gets through the cracks and to provide a safety net," he said.
"People with allergies are currently relying solely on the fact that the packaging says it is 'free from'. Surely more testing along the way - even if it is more time consuming - would be better going forward."
His comments were echoed by other family members.
Celia's daughter Brenna Grice, 22, had gone to get lunch when she returned to find that her mum had collapsed.
She added: "We walked down this street and saw a massive crowd - it was a very distressing scene. Someone we knew came up to us and told us it was our mum on the floor.
"We could not believe that it was our mum. Even though she had allergies, I never believed this would happen to her. I would not wish what had happened to us on any other family.
"After the death of Natasha Ednan-Laperouse you would think lessons would have been learned, and it would not happen again - but it has."
Another daughter Kayleigh Grice, 20, was also shopping with her mum that day but had split to go for separate lunches.
She said: "I do often think that if we had maybe gone with her, then maybe she wouldn't have eaten the sandwich and she would still be there now.
"But obviously Andy was with her, looking after her and checking on her anyway so you just can't think like that.
"Labelling has to be better for people with allergies. There has to be clearer messages. Mum was so on it with labelling, she would triple check everything. If there was any hint that something may contain something she was allergic to, she wouldn't touch it or even go anywhere near it.
"Change has to come to make sure no other family goes through what we went through. This should not happen ever again."
"We miss her smile, and her laugh. We are having to learn to live with it – not seeing her every day. One of the saddest things is we never got a chance to say goodbye. I would love to have one more hug or one more conversation," Kayleigh added.
Celia's mum Jennifer Gower, 72, told how she had been an allergy sufferer from a child and was always vigilant about what she ate.
She added: "Shortly before she died, I remember saying 'just to be safe, don't buy sandwiches from small stores or corner shops, go to a more reputable high street chain as there will be less chance of cross contamination.'"
She said "Ok mum". She followed my advice when she bought that flatbread from Pret a Manger. Even though, she did everything she could, Celia lost her life.
"The biggest message I want to come out of this is that every life matters. Better education about allergies and better support for allergy sufferers is needed so no one goes through what Celia did."
Celia's brother Gareth Gower also demanded more stringent labelling laws and legislation around anything that claims to be "free from".
He added: "Free From' should mean a guaranteed total absence of that allergen from the food and not an interpretation by the manufacturer, with no requirement to test the product to ensure it has not been contaminated.
"Celia's death could have been avoided had a regulated requirement of testing and a mandated safety standard been implemented to verify the "free from" claim.
"We strongly believe "free from" claims on products must be regulated and certified to prevent future tragedy.
"We would like to see the introduction of a "free from" certification mark that can be earned and applied to products to demonstrate conformity to regular testing, auditing and controls and validate the conformity to a "free from" claim.
"Allergy sufferers should not have to gamble with their lives every time they eat outside of the house or try a product that claims to be safe and free from allergies.
"Celia will be greatly missed by her family and friends; she loved to help others and would take some comfort in the cause of her death being used for the improvement of the lives of all food allergy sufferers and national allergy awareness."
Speaking outside the inquest, Celia’s eldest daughter Ashleigh Grice, 27, read a further statement on behalf of the family.
She said: "Our mum Celia was our rock, she was the soul of our family. She wasn’t just our mum, wife, daughter and sister. She was a best friend to us all. She was the family. She was our world.
"We miss her every day and will always carry the unbearable pain of her loss. Never to share her love and laughter again, or to see her as the doting Nan she would have been.
"It is now almost five years since our mum Celia was suddenly and tragically taken from us. She knew she had a serious food allergy.
"Because of that constant fear, mum was extremely cautious in all she ate, checking every label – often triple checking - for dairy.
"On that terrible day she trusted the “dairy-free" labelling in the Pret a Manger store. But the vegan wrap had been contaminated with milk protein. The contents were poisonous to her and she collapsed in the street.
"We would like to thank all the first responders, bystanders and hospital staff who helped our mum Celia on the day she died - especially trained first aider Brendan Turvey, who cared for her at the scene.
"There are many lessons to be learned from our loss to prevent other families suffering as we do:
• The woeful lack of testing in the food supply chain for products that claim to be dairy free or free from
• The inconsistent use by food businesses of vague labelling such as “may contain’ and “produced in a factory where…”
• And the failure of the healthcare system to help people with serious food allergies
"We strongly support the recommendation that food-related anaphylaxis is officially registered as a notifiable disease. This would help save lives.
"Finally, we would like to thank the Coroner for her verdict today and our amazing legal team of Jeremy Hyam, Hannah Noyce, and Leigh Day. The inquest has helped bring us closer to some answers.
"It is now clear to us that if Planet Coconut had passed on the warnings in their possession to Pret a Manger about the risk of cross-contamination mum would still be alive today. Mum’s death, like so many other allergy deaths, was entirely avoidable.
"As a family we believe that action must be taken now by the food industry and the government. We need better testing, better labelling, and better healthcare.
"To prevent other families having to carry the grief that we will always hold.
"Enough is enough."
Also peaking at the inquest, Shawn Eyles, one of the paramedics who attended, said some shoppers continued to step over her as she was being treated.
The wrap had been consumed in its entirety, and the pot of CoYo brand yoghurt used to make it was thrown away before Bath and North East Somerset Council began its investigation.
But testing on other pots found small quantities of dairy protein in the product, with traces found in another rainbow wrap.
During the two-week inquest, a chemist acknowledged the quantity of dairy in the wrap was too low to be measured with any degree of accuracy, but said he believed it definitely contained milk.
It is thought the contamination stemmed from the HG1 starch in the yoghurt.
Interested parties in the inquest were Bath and North East Somerset Council, CoYo and Planet Coconut.
Bethany Eaton, the managing director of Planet Coconut, broke down in tears as she gave evidence during the inquest, the BBC reports.
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.
She went on to say that since Mrs Marsh's death, all products are now tested, irrespective of the source.
Mrs Marsh's death came in the wake of that of 15-year-old Natasha Ednan-Laperouse, who died in 2016 after eating a Pret baguette containing sesame seeds, bought at Heathrow Airport.
Ms Ednan-Laperouse had a sesame allergy.
