First reported 10 May 2019•Latest report 20 Aug 2024
Definition
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.
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.
Reports
5
Distinct published reports
Individual concerns
6
A report can raise multiple concerns
Date range
2019–2024
First to latest report issue date
Stated actions
21
Described in published responses
Reports over time
Reports 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
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Maintain guidance on school use of adrenaline auto-injectors under review, including access during travel to and from school.
Stated by Department for EducationStated in progressThe respondent said that this action was in progress when they made their response on 30 August 2024.
Action
Publish guidance enabling schools to obtain and use spare adrenaline auto-injectors in emergencies, including advice on carrying two devices and access during travel.
Stated by Department for EducationStated completedThe respondent said that this action was complete when they made their response on 30 August 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Current MHRA guidance is considered sufficient to address advice on carrying two adrenaline autoinjectors and using them promptly; no revision is planned.
Stated by Department for EducationExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing school duties and guidance are considered sufficient to require allergy arrangements and access to adrenaline autoinjectors during travel to and from school.
Stated by Department for EducationExisting 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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Develop and maintain allergy action plans distinguishing mild or moderate reactions from anaphylaxis and advising adrenaline if in doubt.
Stated by The British Society For Allergy & Clinical ImmunologyStated completedThe respondent said that this action was complete when they made their response on 30 August 2024.
Action
Develop an online allergy education platform covering anaphylaxis recognition, symptoms and management for healthcare and non-healthcare professionals.
Stated by The British Society For Allergy & Clinical ImmunologyStated in progressThe respondent said that this action was in progress when they made their response on 30 August 2024.
Action
Develop anaphylaxis guidelines and patient information leaflets with patient organisations, including an accessible leaflet explaining anaphylaxis signs and symptoms.
Stated by The British Society For Allergy & Clinical ImmunologyStated completedThe respondent said that this action was complete when they made their response on 30 August 2024.
Action
Work with professional bodies to agree and support allergy standards of care and education.
Stated by Royal College of PhysiciansStated plannedThe respondent said that this action was planned when they made their response on 30 August 2024.
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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Review and update the Specialist Allergy Service Specification, including stronger transition, self-care, information and personal management plan requirements.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 12 February 2024.
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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.14
Action
Amend and release the Distance Learning Pack with stronger anaphylaxis guidance, second-dose adrenaline advice and accurate images of adrenaline autoinjectors.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.
Action
Amend NHS Pathways guidance so a second adrenaline autoinjector is advised after five minutes without improvement, through Release 20.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2020.
Action
Disseminate prescribing, dosing, device-change and training guidance for adrenaline auto-injectors through safety bulletins, newsletters, intranet updates, scriptswitch messages and practice events.
Stated by NHS Enfield Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.
Action
Follow up practices through meetings and training, and collate records confirming patient device training and dosage reviews.
Stated by NHS Enfield Clinical Commissioning GroupStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2020.
Action
Process AAI prescriptions as acute prescriptions and provide device-specific safety instructions covering appropriate dosing, carrying two pens and emergency action.
Stated by the three G.Ps that were interested persons in the above matterStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.
Action
Train clinical staff on the three common AAI devices and maintain sample pens for patient demonstrations and training.
Stated by the three G.Ps that were interested persons in the above matterStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.
Action
Deliver enhanced anaphylaxis content within mandatory basic life-support training, including symptom recognition, carrying two pens and device-specific administration.
Stated by the three G.Ps that were interested persons in the above matterStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.
Action
Recruit an in-house pharmacist to provide current AAI guidance and patient training during prescribing and dispensing.
Stated by the three G.Ps that were interested persons in the above matterStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.
Action
Appoint a Practice Anaphylaxis Champion to oversee staff awareness, training, prescribing surveillance, protocol adherence and patient reviews.
Stated by the three G.Ps that were interested persons in the above matterStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2020.
Action
Amend the ScriptSwitch message with AAI availability, prescribing, dose-checking, counselling, training and allergy-action-plan requirements.
Stated by the three G.Ps that were interested persons in the above matterStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.
Action
Have commissioning teams liaise with relevant organisations to facilitate uptake of new guidance and resources supporting management of severe allergies.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 13 August 2020.
Action
Consider whether communication routes or commissioning levers can support uptake and embedding of new allergy guidance and resources.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 13 August 2020.
Action
Initiate discussions with MHRA about adding advice to outer packaging that patients should carry two adrenaline auto-injectors.
Stated by Bausch & Lomb U.K. LimitedStated plannedThe respondent said that this action was planned when they made their response on 13 August 2020.
Action
Consider how best to clarify in CG134 that two adrenaline auto-injectors should be prescribed and carried at all times.
Stated by National Institute for Health and Care ExcellenceStated plannedThe respondent said that this action was planned when they made their response on 13 August 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Matters of concern 1–14 and 20 do not concern NHS Pathways and fall outside its remit.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
Routine twin-pack supply cannot replace single-pen dispensing or patient education about carrying two auto-injectors.
Stated by Bausch & Lomb U.K. LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing BNF and BNFc advice sufficiently covers adrenaline auto-injector doses, quantities and training, so NICE will not duplicate that advice.
Stated by National Institute for Health and Care ExcellenceExisting 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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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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.
