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Family of Celia Marsh renew call for mandatory reporting of anaphylaxis

The family of Celia Marsh have renewed their calls for mandatory reporting of near fatal and fatal anaphylactic reactions as a notifiable disease following the publication of Senior Coroner Maria Voisin’s Prevention of Future Deaths report (PFD).

Posted on 05 December 2022

Celia’s family believe a robust system should be established in order to record cases of anaphylaxis which would provide vital early warnings of the potential risks posed to allergic individuals by products with undeclared allergens.

Celia Marsh

The Marsh family have welcomed the coroner’s Prevention of Future Deaths report which includes a suggestion that a system could be established which could involve mandatory reporting of near fatal and fatal anaphylactic reactions of individuals attending hospital. This could be similar to the current system used for notifiable diseases.

Registered medical practitioners would have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team. This will hopefully mean that cases will be dealt with promptly which would avoid other families losing loved ones in the way they did.

Celia died on 27 December 2017 from anaphylaxis caused by the consumption of a flatbread which was marked as ‘dairy-free’ and ‘vegan’ but was contaminated with milk protein.

Celia’s family have 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. Some of the key suggestions, as well as the mandatory reporting, 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.
  • That appropriate advice is given to individuals by medical professionals. This will ensure that 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”. Products labelled as “free from” should mean just that and be completely free from that allergen. 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 Food Standards Agency is to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.

Celia’s family said:

“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.”

Michelle Victor, partner at law firm Leigh Day, 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.”

Michelle Victor
Environment Food safety Inquests Medical devices Personal injury Product safety

Michelle Victor

Michelle is a leading consumer rights lawyer and head of the food safety team in London

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