First reported 25 Apr 2016•Latest report 25 Nov 2025
Definition
What this concern includes
Includes failures of controls specifically dedicated to recognising, assessing, communicating or responding to suspected anaphylaxis, including symptom recognition, distinction from mild reactions, appropriate testing, escalation, treatment and patient or family safety information.
Not included
Excludes generic clinical recognition or escalation failures where anaphylaxis is not the identified hazard.
Excludes management of other allergic, respiratory or infectious conditions unless the assertion explicitly concerns suspected anaphylaxis.
Excludes failures limited to treatment after anaphylaxis was reliably recognised and escalated, unless the treatment control itself is part of the anaphylaxis response.
Excludes generic staff training, communication or documentation deficiencies that are not directly tied to anaphylaxis recognition or response.
Reports
5
Distinct published reports
Individual concerns
8
A report can raise multiple concerns
Date range
2016–2025
First to latest report issue date
Stated actions
28
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.
Medicines and Healthcare products Regulatory Agency2
NHS England2
Advanced Health And Care Limited1
Association of Ambulance Chief Executives1
Bausch & Lomb U.K. Limited1
Cambridgeshire Constabulary1
Department for Environment, Food & Rural Affairs1
Department of Health and Social Care1
General Dental Council1
General Pharmaceutical Council1
London Ambulance Service NHS Trust1
London Central & West Unscheduled Care Collaborative Limited1
Manchester University NHS Foundation Trust1
National Institute for Health and Care Excellence1
NHS Enfield Clinical Commissioning Group1
Executive non-departmental public body2
Health professional body2
Medicines and medical devices regulator2
Ministerial department2
NHS trust2
Private limited company2
Clinical commissioning group1
Health and care professional regulator1
Healthcare site1
Health-sector membership body1
Independent healthcare provider1
Integrated care board1
Police force1
Professional body1
Registered charity1
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.
Cambridgeshire and Peterborough
Concerns raised1
Failure to collect blood samples for mast cell tryptase and specific IgE serology in suspected anaphylaxis
This report raised 7 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.2
Action
Publish autopsy guidelines for suspected acute anaphylaxis, including blood and stomach-content sampling guidance.
Stated by Royal College of PathologistsStated completedThe respondent said that this action was complete when they made their response on 2 December 2025.
Action
Query the relevant guideline authors about adding IgE testing to an updated autopsy guideline.
Stated by Royal College of PathologistsStated plannedThe respondent said that this action was planned when they made their response on 2 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Published anaphylaxis autopsy guidance and expected use of relevant guidance are considered sufficient despite paediatric guidelines lacking specific anaphylaxis details.
Stated by Royal College of PathologistsExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East London
Concerns raised3
Allergy plans failing to distinguish lip swelling as a potential anaphylaxis symptom
Failure to recognise inability to swallow as a sign of anaphylaxis in dental settings
Lack of sufficiently clear distinction between anaphylactic and mild reactions
This report raised 2 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.9
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
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.
Action
Update allergy accreditation standards, including adoption of the BSACI adult allergy action plan.
Stated by Royal College of PhysiciansStated plannedThe respondent said that this action was planned when they made their response on 30 August 2024.
Action
Continue widely promoting Paediatric Allergy Training study days across the child health workforce.
Stated by Royal College of Paediatrics and Child HealthStated in progressThe respondent said that this action was in progress 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
Roll out the online allergy education platform extensively to healthcare professionals, non-healthcare professionals and other relevant stakeholders.
Stated by The British Society For Allergy & Clinical ImmunologyStated plannedThe respondent said that this action was planned when they made their response on 30 August 2024.
Action
Write to NICE requesting review of anaphylaxis symptoms and related guidance for dental professionals.
Stated by General Dental CouncilStated plannedThe respondent said that this action was planned when they made their response on 30 August 2024.
Action
Review CPD requirements and consider proposing changes to medical-emergency recommendations.
Stated by General Dental CouncilStated 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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
The current standards and guidance provide clear obligations, so additional or different standards are not currently considered necessary.
Stated by General Dental CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Potential CPD changes requiring legislation may be delayed because the timing of legislative changes is outside the respondent’s control.
Stated by General Dental CouncilUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Excess salivation is not listed as anaphylaxis in national guidance, so dental staff reasonably did not interpret it as early anaphylaxis.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Training dentists and dental staff, and supplying adrenaline auto-injectors to pharmacies, fall outside the organisation’s role.
Stated by Royal College of Paediatrics and Child HealthOutside remitThe respondent said that this matter was outside its role or authority.
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.
London (West)
Concerns raised1
Inadequate adrenaline dose for anaphylaxis
This report raised 3 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.3
Action
Conducted and progressed a European safety review of adrenaline auto-injectors, including assessment of needle length and clinical effectiveness evidence.
Stated by Medicines and Healthcare products Regulatory AgencyStated completedThe respondent said that this action was complete when they made their response on 9 October 2018.
Action
Evaluating clinical study data for each adrenaline auto-injector brand as submissions become available.
Stated by Medicines and Healthcare products Regulatory AgencyStated in progressThe respondent said that this action was in progress when they made their response on 9 October 2018.
Action
Conducting an overarching evaluation of all adrenaline auto-injector study data to determine whether further safety measures are needed.
Stated by Medicines and Healthcare products Regulatory AgencyStated plannedThe respondent said that this action was planned when they made their response on 9 October 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The 500 microgram adrenaline recommendation applies to healthcare professionals’ manual injections, not auto-injector self-administration.
Stated by Medicines and Healthcare products Regulatory AgencyDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester City
Concerns raised1
Failure to recognise and act on symptoms of possible anaphylactic shock
This report raised 3 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 controls specifically dedicated to recognising, assessing, communicating or responding to suspected anaphylaxis, including symptom recognition, distinction from mild reactions, appropriate testing, escalation, treatment and patient or family safety information.
