Inadequate anaphylaxis safety education for patients, parents and schools
First to latest report 10 May 2019 — 20 Aug 2024
Reports that mention this concern
5
Times this concern has been raised
6
Stated actions linked to this concern
21
What this concern includes
Includes failures of education, safety advice, practical instruction or structured support specifically intended to help people with anaphylaxis or allergy, their parents or carers, and schools understand anaphylaxis risks and safely carry or use adrenaline auto-injectors.
What is not included
Excludes clinical recognition, diagnosis or emergency treatment failures where the deficient control is not an education or safety-information arrangement.
Excludes general allergy or anaphylaxis service-management deficiencies where no education, advice or practical safety-information failure is identified.
Excludes medication-packaging and product-labelling deficiencies, including missing instructions on EpiPen packaging, unless the report also identifies a patient-, parent- or school-facing education failure.
Excludes generic school safeguarding, health education or parental-support deficiencies without a direct anaphylaxis safety-education connection.
Trends
Reports over time
Reports mentioning this concern, over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Department of Health and Social Care4
NHS England3
Department for Education2
London Ambulance Service NHS Trust2
Royal College of Paediatrics and Child Health2
The British Society For Allergy & Clinical Immunology2
Advanced Health And Care Limited1
Association of Ambulance Chief Executives1
Bausch & Lomb U.K. Limited1
General Dental Council1
General Pharmaceutical Council1
London Central & West Unscheduled Care Collaborative Limited1
London North West University Healthcare NHS Trust1
Medicines and Healthcare products Regulatory Agency1
National Institute for Health and Care Excellence1
Ministerial department4
Executive non-departmental public body3
NHS trust2
Professional body2
Registered charity2
Clinical commissioning group1
Company1
English metropolitan district council1
Free school1
Health and care professional regulator1
Healthcare site1
Health professional body1
Health-sector membership body1
Independent healthcare provider1
Integrated care board1
Reports and published responses 5 reports
See individual reports that have raised this concern, and the actions taken in response
East London
Concerns raised1
Absence of an appropriate structure to educate schools, patients and parents about carrying adrenaline autoinjectors during journeys to and from school
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Department for Education
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Department for Education
Maintain guidance on school use of adrenaline auto-injectors under review, including access during travel to and from school.
Department for Education
Publish guidance enabling schools to obtain and use spare adrenaline auto-injectors in emergencies, including advice on carrying two devices and access during travel.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Department for Education
Current MHRA guidance is considered sufficient to address advice on carrying two adrenaline autoinjectors and using them promptly; no revision is planned.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Department for Education
Existing school duties and guidance are considered sufficient to require allergy arrangements and access to adrenaline autoinjectors during travel to and from school.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East London
Concerns raised1
Insufficient education of parents and patients on safe AAI use when in doubt
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Royal College of Physicians
The British Society For Allergy & Clinical Immunology
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
The British Society For Allergy & Clinical Immunology
Develop and maintain allergy action plans distinguishing mild or moderate reactions from anaphylaxis and advising adrenaline if in doubt.
The British Society For Allergy & Clinical Immunology
Develop an online allergy education platform covering anaphylaxis recognition, symptoms and management for healthcare and non-healthcare professionals.
The British Society For Allergy & Clinical Immunology
Develop anaphylaxis guidelines and patient information leaflets with patient organisations, including an accessible leaflet explaining anaphylaxis signs and symptoms.
Royal College of Physicians
Work with professional bodies to agree and support allergy standards of care and education.
Newcastle and North Tyneside
Concerns raised1
Lack of an appropriate structure to educate and manage people diagnosed with allergies and anaphylaxis
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
NHS England
Review and update the Specialist Allergy Service Specification, including stronger transition, self-care, information and personal management plan requirements.
Inner North London
Concerns raised2
Failure to explain the need for sequential administration of two adrenaline auto injectors in acute anaphylaxis
Failure to record and emphasise the need to carry two adrenaline auto injector pens
This report raised 19 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Bausch & Lomb U.K. Limited
National Institute for Health and Care Excellence
NHS Enfield Clinical Commissioning Group
NHS England
the three G.Ps that were interested persons in the above matter
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.14
NHS England
Amend and release the Distance Learning Pack with stronger anaphylaxis guidance, second-dose adrenaline advice and accurate images of adrenaline autoinjectors.
NHS England
Amend NHS Pathways guidance so a second adrenaline autoinjector is advised after five minutes without improvement, through Release 20.
NHS Enfield Clinical Commissioning Group
Disseminate prescribing, dosing, device-change and training guidance for adrenaline auto-injectors through safety bulletins, newsletters, intranet updates, scriptswitch messages and practice events.
NHS Enfield Clinical Commissioning Group
Follow up practices through meetings and training, and collate records confirming patient device training and dosage reviews.
the three G.Ps that were interested persons in the above matter
Process AAI prescriptions as acute prescriptions and provide device-specific safety instructions covering appropriate dosing, carrying two pens and emergency action.
the three G.Ps that were interested persons in the above matter
Train clinical staff on the three common AAI devices and maintain sample pens for patient demonstrations and training.
the three G.Ps that were interested persons in the above matter
Deliver enhanced anaphylaxis content within mandatory basic life-support training, including symptom recognition, carrying two pens and device-specific administration.
the three G.Ps that were interested persons in the above matter
Recruit an in-house pharmacist to provide current AAI guidance and patient training during prescribing and dispensing.
the three G.Ps that were interested persons in the above matter
Appoint a Practice Anaphylaxis Champion to oversee staff awareness, training, prescribing surveillance, protocol adherence and patient reviews.
the three G.Ps that were interested persons in the above matter
Amend the ScriptSwitch message with AAI availability, prescribing, dose-checking, counselling, training and allergy-action-plan requirements.
NHS England
Have commissioning teams liaise with relevant organisations to facilitate uptake of new guidance and resources supporting management of severe allergies.
NHS England
Consider whether communication routes or commissioning levers can support uptake and embedding of new allergy guidance and resources.
Bausch & Lomb U.K. Limited
Initiate discussions with MHRA about adding advice to outer packaging that patients should carry two adrenaline auto-injectors.
National Institute for Health and Care Excellence
Consider how best to clarify in CG134 that two adrenaline auto-injectors should be prescribed and carried at all times.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
NHS England
Matters of concern 1–14 and 20 do not concern NHS Pathways and fall outside its remit.
Outside remitThe respondent said that this matter was outside its role or authority.
Bausch & Lomb U.K. Limited
Routine twin-pack supply cannot replace single-pen dispensing or patient education about carrying two auto-injectors.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
National Institute for Health and Care Excellence
Existing BNF and BNFc advice sufficiently covers adrenaline auto-injector doses, quantities and training, so NICE will not duplicate that advice.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner North London
Concerns raised1
Lack of school pupil understanding of allergies and the consequences of allergen exposure
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.