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Coroner demands action to prevent future deaths following Natasha Ednan-Laperouse inquest

​A Prevention of Future Deaths report has been published following the inquest into the death of Natasha Ednan-Laperouse who died of anaphylaxis on the 17th July 2016 after eating a baguette, purchased from Pret a Manger, which contained sesame.

Natasha Ednan-Laperouse

10 October 2018

The report was made by coroner Dr Sean Cummings and is addressed to Clive Schlee, chief executive of Pret a Manger; the Medicines and Healthcare products Regulatory Agency (MRHA); the chief executive of Pfizer makers of the EpiPen; and Secretary of State Department for the Environment, Food and Rural Affairs Michael Gove.
 
A Prevention of Future Deaths report can be made by a coroner if they feel that the evidence given during an inquest shows that there is a risk of further deaths unless action is taken.
 
Some of the concerns listed in the report by the coroner included that “allergens were not labelled adequately or clearly on Pret a Manger packaging when prepared in their kitchens ‘pre-packed for direct sale’ utilising regulation 5 of the Food Information Regulations” and that at Pret a Manger “there was no coherent or co-ordinated system for monitoring customer allergic reactions despite sales of more than 200 million items”.
 
The coroner also noted that expert evidence given at the inquest stated that the preferred length of needle for adrenaline injectors is 25mm, but that the length of the needle in an Epipen is 16mm. The inquest also heard that The UK Resuscitation Council recommends a standard emergency dose of 500mcg adrenaline for anaphylaxis, the dose in an Epipen is 300mcg.
 
All four recipients of the report have a duty to respond within 56 days detailing and action taken or action proposed to be taken and a timetable for action. If no action is taken or proposed they are required to explain why.
 
Thomas Jervis, solicitor representing the Ednan-Laperouse family, said:

“We are pleased that the coroner has issued this report to request action in order to prevent any further loss of life. It was clear from the inquest that policies, procedures and regulations need to change urgently to ensure the safety of all allergy sufferers.”

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