21 Nov 2022 Celia Lindsey MARSH · Prevention of Future Deaths report Avon
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Concerns raised 2
Potentially unsafe exposure to undeclared allergens for people at significantly higher risk of fatal reactions View source Lack of robust confirmation of allergen absence in ingredients and production View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
British Retail Consortium Food and Drink Federation UK Health Security Agency UKHospitality
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
British Retail Consortium
Developed and published guidance on manufacturing and labelling free-from products, with input from regulators and allergy charities.
View source
UKHospitality
Publish an updated Industry Catering Guide covering legal obligations, good hygiene practice, allergens, and preventing cross-contact when making “free from” claims.
View source
UKHospitality
Consult members through expert policy groups on managing the risk of vegan dishes for people with hypersensitivity.
View source
Food and Drink Federation
Produce industry guidance explaining appropriate use of free-from allergen claims and required risk controls.
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AI-generated summary
Celia Lindsey MARSH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Celia Lindsey Marsh died on 27 December 2017 after suffering fatal anaphylaxis caused by milk protein in a wrap she believed was safe to eat. The principal concerns included the investigation and retention of evidence in suspected anaphylaxis deaths, education for doctors and patients, systems for reporting anaphylaxis, and potentially misleading “dairy-free” and other allergen-labelling claims.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Potentially unsafe exposure to undeclared allergens for people at significantly higher risk of fatal reactions
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group .
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” Source location Celia Lindsey MARSH · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of robust confirmation of allergen absence in ingredients and production
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim .
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” Source location Celia Lindsey MARSH · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Developed and published guidance on manufacturing and labelling free-from products, with input from regulators and allergy charities.
Verbatim wording from the response “In the absence of more specific requirements, the BRC, jointly with the Food and Drink Federation (FDF), worked on a guidance document on how to manufacture and label ‘free-from’ products**. The Food Standards Agency and allergy charities were consulted during the development process of the document. The document is used by our members and is publicly available for other companies to use.” Source location Response from British Retail Consortium
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish an updated Industry Catering Guide covering legal obligations, good hygiene practice, allergens, and preventing cross-contact when making “free from” claims.
Verbatim wording from the response “Prior to the publication of your report and the specific recommendations for UKHospitality, we released in early November 2022 an updated version of our Industry Catering Guide to” Source location Response from UK Hospitality
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consult members through expert policy groups on managing the risk of vegan dishes for people with hypersensitivity.
Verbatim wording from the response “It is clear to see that the market for vegan dishes has grown substantially over the last few years. Many businesses across the UK offer a number of vegan options on menus, with vegan restaurants continuing to grow in popularity. When making specific claims around vegan dishes, whilst it is important to provide customers with as accurate information as possible, statements regarding vegan food is not a hypersensitivity issue. However, we recognise the importance of the issues set out in your report and commit to carrying out a consultation with members in the aforementioned expert groups on managing the risk of vegan dishes for people with hypersensitivity, and reflecting any recommendations in future updates to the Industry Guidance.” Source location Response from UK Hospitality
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce industry guidance explaining appropriate use of free-from allergen claims and required risk controls.
Verbatim wording from the response “In 2015, aware that a growing number of food business operators - including manufacturers, retailers and caterers - were making such claims for their food products, the FDF produced industry guidance in conjunction with the BRC to explain the appropriate use of “free-from” claims in relation to food allergens. The guide clarifies that a “free-from” claim is the absence of a specific food allergen in any food and must be based on a comprehensive risk assessment accompanied by rigorous controls (which should include analytical testing). This is to ensure that the claim is valid and not misleading.” Source location Response from Food and Drink Federation
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Practitioners and allergy clinicians should explain that free-from products are not safe for all allergic consumers after diagnosis.
Verbatim wording from the response “Regarding the second recommendation - including a statement that ‘free-from’ products are not safe for all allergic consumers - we believe such an explanation should be given by practitioners and allergy clinicians, after patient diagnosis, when explaining and guiding allergic patients on how to manage their diets. The statement could have unintended consequences confusing customers and potentially contradicting what their medical teams have advised and limiting their food choices.” Source location Response from British Retail Consortium
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The majority of allergic people can safely consume free-from products, so a universal warning could mislead consumers and restrict choices.
Verbatim wording from the response “Regarding the second recommendation - including a statement that ‘free-from’ products are not safe for all allergic consumers - we believe such an explanation should be given by practitioners and allergy clinicians, after patient diagnosis, when explaining and guiding allergic patients on how to manage their diets. The statement could have unintended consequences confusing customers and potentially contradicting what their medical teams have advised and limiting their food choices.” Source location Response from British Retail Consortium
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual retail businesses, rather than the trade association, are responsible for decisions about product labels and associated policies.
Verbatim wording from the response “We support our members with their decision process on what appears on labels and associated policies, but it is their individual company responsibility to make the decision.” Source location Response from British Retail Consortium
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation FSA and HSE are responsible for food policy, while DHSC is responsible for nutrition and health campaigns.
Verbatim wording from the response “The Food Standards Agency (FSA) and the Health and Safety Executive (HSE) hold responsibility for food policy related matters. When Public Health England (PHE) became UKHSA the responsibility for nutrition and health campaigns transferred to the Department of Health and Social Care (DHSC).” Source location Response UK Health Security Agency
Open published response
16 Jan 2014 Jackie Scott · Prevention of Future Deaths report North Northumberland
View report summary
Concerns raised 1
Unidentified presence of peanuts or peanut oil in purchased food View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Jackie Scott · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jackie Scott became ill and lost consciousness after eating a takeaway curry while staying at a campsite in Seahouses on 20 June 2013. He died at Wansbeck General Hospital from acute anaphylaxis; the principal concern was that the meal may have contained peanuts or peanut oil without his knowledge.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unidentified presence of peanuts or peanut oil in purchased food
Wider context from the report “I was informed at the Inquest by Jackie Scott’s parents that he had been able to eat take-away curries in the past without any problems but it is believed that his allergic reaction was likely to have arisen from consuming food containing peanuts or peanut oil . It seems that Jackie Scott would have been unaware that the food he purchased (Tikka Massala) may have contained peanut oil or peanuts . Given the timing of his sudden allergic reaction which occurred as soon as he ate the meal, which sadly lead to his death from anaphylactic shock, it is almost certain that this was a result of the meal he consumed without knowing that it contained peanuts or peanut oil .
” Source location Jackie Scott · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.