Mother of milk allergy teenager Hannah Jacobs calls for serious changes in anaphylaxis training

Hannah Jacobs, pictured, was diagnosed as a toddler with severe allergies to dairy, egg, fish and wheat, which were diligently managed throughout her life. 

The inquest into Hannah’s death ended on Friday 16 August with a narrative conclusion welcomed by Hannah’s mother Abi Duyile and her family. 
 
Assistant coroner Dr Shirley Radcliffe said the root cause of Hannah’s death were failings of the staff at the Costa Coffee store in Barking to follow the processes in place when Abi had declared Hannah had an allergy. This was combined with a clear lack of comprehension. 
 
Although Abi did not carry an EpiPen there was an opportunity to save her life at the East Street Dental Practice as they had adrenaline. However, the coroner considered there was insufficient time and information to understand the rapidly evolving emergency.  
 
Once at the Daynight pharmacy, Hannah was close to death and required an adult dose of adrenaline. The coroner confirmed that on the balance of probabilities, if Hannah had received an adult dose of adrenaline it cannot be said she would have survived. 
 
Abimbola Duyile, Hannah’s mother, said following the inquest: 
  
“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 not taken seriously enough. Better awareness is needed in these industries and across society of the symptoms of anaphylaxis. 
 
“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. Being a medical professional and not reacting quickly to even a possible anaphylactic reaction 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.  
 
“I truly believe that with Hannah’s confidence, deep sense of right and wrong and her natural thoughtfulness and affectionate nature she could have achieved so much in this world.” 
 
Michelle Victor, head of the food safety team at Leigh Day, said:  
  
“No mother should have to bury their child, and no further lives should be lost due to food induced anaphylaxis. There are still many lessons to be learned. 
  
“While we welcome the information provided by Costa that their training has changed since Hannah’s death Abi still believes that much more can be done. Robust training for those in the food service industry is essential and it must be rigorously tested to ensure it is fully understood and consistently implemented. This must be industry-wide. 
  
“Abi and her family want meaningful changes to prevent any further deaths including the following changes:  
 
“First, food businesses to come together to provide extra safeguards by implementing a process for the order details to be printed and stuck to coffee cups. 
  
“Second, we welcome the coroner’s decision to write to the Department of Education and the Department of Health to consider the practicalities of children with allergies carrying adrenaline when travelling to and from school. 
  
“Third, the Department of Health to provide further education to the general public, medical professional and businesses on managing allergic reactions which require adrenaline. 
  
“Last but not least, Abi supports the call by The Natasha’s Allergy Research Foundation for a dedicated person in Government to ensure people with allergies receive proper support and joined up healthcare to prevent avoidable deaths and ill health.”

On 8 February 2023 Hannah attended a branch of Costa Coffee in Barking, run by franchisee SBR Trading, with her mother. Her mother Abi told the inquest she had ordered two soya milk hot chocolates, told the barista that Hannah had a dairy allergy and asked her to clear the jug and utensils before making the drink.  
 
The barista who took the order had completed the relevant allergy training mandated by Costa and SBR trading Ltd. Evidence was given at the inquest that it was company policy for customers who ask for a non-dairy product or state they have an allergy to be shown a book that is kept under the till which confirms the presence or risk or allergens in each food or drink item  This was not offered when Abi placed the order, despite her informing staff of Hannah’s dairy allergy.  
 
The inquest also heard from an area manager for SBR Trading Ltd, that there was no requirement to complete the online allergy training modules in the presence of colleagues and the modules could be done at home. He also said that he would not be aware how many times a new starter had taken the quiz at the end of their training and that it was “not concerning” if a staff member did not understand the word “allergen”. 
 
The court heard of one example where a store manager had been allowed to retake the allergy training quiz 20 times before they finally passed. One witness told the court that she had used Google translate to help her complete the staff training modules. 
  
After purchasing the drinks at the Costa Coffee store, Hannah and her mother walked to the East Street dental surgery nearby to wait for Hannah’s appointment. While in the waiting room Hannah took a couple sips of her hot chocolate then went to the toilet because she was experiencing an allergic reaction and telephoned her mother confirming that the hot chocolate was not made with soya milk. 
 
The court also heard that the dentist visited by Hannah had completed their training on managing medical emergencies including anaphylaxis 12 months previously, and yet did not identify that Hannah was having an anaphylactic reaction and did not administer adrenaline, despite having access to adrenaline on the premises. 
 
The court heard that all staff at the dental surgery had training which included how to administer adrenaline. It was also heard  that the relevant guidelines instruct practitioners to lie a patient flat with their legs raised, administer adrenaline, and call 999 if anaphylaxis is suspected. This was not done by any of the dental staff. 
 
The inquest heard evidence from a consultant paediatric allergist, who said that if there is any doubt whether a person is experiencing anaphylaxis, adrenaline should be given without delay.  
 
Abi then took Hannah to nearby Daynight pharmacy where Hannah’s condition deteriorated and Abi asked the pharmacist for cetirizine (an antihistamine) and an EpiPen. The pharmacist administered one dose from a junior EpiPen, which the inquest heard was not adequate as Hannah should have received two doses from an adult EpiPen. A bystander called 999 as the EpiPen was being prepared. 
 
The pharmacist used a junior EpiPen on Hannah as no adult doses were available, and told the court he instructed his staff to look around for adult EpiPens but none could be found. 
 
Tragically, Hannah’s anaphylactic reaction escalated rapidly, and she lost consciousness shortly after the EpiPen Junior was administered.  A Rapid Response Paramedic arrived around five minutes after the 999 call was made, and a double-crewed ambulance arrived a few minutes later. Hannah was treated at the scene by the London Ambulance Service and Helicopter Emergency Medical Service (HEMS) for close to an hour before being transferred to Newham Hospital. She died at 1pm after resuscitation efforts were discontinued. 
 
Hannah’s mother was represented at the inquest by Michelle Victor, Angela Bruno and Andrew Jackson, of law firm Leigh Day and barrister Emily Slocombe of Old Square Chambers.