Recurring concern

Unreliable capture and reporting of anaphylaxis incidents

Get email alerts

Request correction

First reported 4 Jan 2018•Latest report 6 Apr 2023

Definition

What this concern includes

Includes failures in dedicated processes for recognising, recording, notifying or escalating anaphylaxis incidents, including non-fatal, near-fatal and fatal cases, to relevant food-safety, public-health or other regulatory authorities when the information is needed for investigation, surveillance or preventive action.

Not included

Excludes general allergy education, clinical treatment, prescribing or follow-up failures where anaphylaxis incident capture or reporting is not the deficient control.
Excludes food labelling, allergen-free food preparation and commercial food-safety controls where no failure to capture or report an anaphylaxis incident is identified.
Excludes coronial, pathology or postmortem investigation failures after the anaphylaxis incident has been reliably captured and reported.
Excludes generic information-sharing or incident-reporting deficiencies without a material anaphylaxis context.
Excludes barriers to sharing information about deceased patients where the assertion does not specifically concern capturing or reporting an anaphylaxis incident.

Reports: 5
Individual concerns: 8
Date range: 2018–2023
Stated actions: 19

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care5

Food Standards Agency4

The British Society For Allergy & Clinical Immunology2

British Retail Consortium1

Byron Hamburgers Limited1

Department for Environment, Food & Rural Affairs1

Food and Drink Federation1

Medicines and Healthcare products Regulatory Agency1

Ministry of Housing, Communities and Local Government1

National Trading Standards1

Recipient name withheld1

Royal College of Pathologists1

UK Fatal Anaphylaxis Registry1

UK Health Security Agency1

UKHospitality1

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.

6 Apr2023
Berkshire
Concerns raised3
1. Failure to mandate referral of fatal anaphylaxis cases
2. Lack of a national reporting and fatality-register system for anaphylaxis
3. Failure to robustly capture and record fatal and near-fatal anaphylaxis cases
This report raised 6 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 1
1. Action
  Develop a mechanism for sharing relevant patient-safety anaphylaxis incidents with the UK Fatal Anaphylaxis Registry.
  Stated by NHS EnglandStated in progress
AI-generated summary

Alexandra Briess · 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

Alexandra Briess underwent tonsillectomy, later required surgery for post-operative bleeding, and suffered sudden deterioration and cardiac arrest during anaesthesia on 30 May 2021. She died on 31 May 2021, with the most likely cause identified as an anaphylactic reaction to Rocuronium; there were no concerns about her clinical management. The principal concerns were the lack of national leadership and funding for anaphylaxis work, mandatory reporting of fatal anaphylaxis, and improved national data gathering, research and information sharing.

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
Failure to mandate referral of fatal anaphylaxis cases
Wider context from the report
“It seems clear to all coroners in these cases, and those involved in this area of medical expertise, that the only way to improve understanding and prevent or reduce future deaths is to gather information nationally and fund appropriate research. Appropriate organisations already exist, and there is a lot of goodwill towards improving understanding in this area. It does however require national leadership and “joining up” of these organisations. 1. I have tried to make my list of issues clear and succinct. Paragraph 2 below sets out the crux of this ongoing risk. 2. There is significant goodwill and desire to improve amongst numerous organisations involved in anaphylaxis work. What is lacking is national leadership and funding. In my view, consideration should be given to creating a leadership role and responsibility within NHS England to coordinate a national approach. 3. As considered by other coroners before me, it should be mandatory to refer fatal anaphylaxis cases. UKFAR has indicated that they would be prepared to take on the role of receiving these reports (to avoid duplication for reporting clinicians), with the responsibility to forward the relevant information to other organisations such as the MHRA, where appropriate. Whilst my focus is on fatal anaphylaxis, inclusion of non-fatal cases would be a matter for the lead role to consider. 4. Gathering data and using this to research and reduce the risk of future deaths requires funding, and this should be reviewed. ”
Source location
Alexandra Briess · Prevention of Future Deaths report
Page 4 · concerns
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 a national reporting and fatality-register system for anaphylaxis
Wider context from the report
““In my opinion action should be taken to consider establishing a national reporting system which includes timely reporting to local authority and FSA and maintenance of a register of fatalities and their investigations, and consideration be given to investigating the feasibility of wider access to AAI’s. I believe that the organizations would wish to learn of the circumstances of this death and are in a position to facilitate a collaborative process to mitigate or prevent future deaths.” ”
Source location
Alexandra Briess · Prevention of Future Deaths report
Page 3 · concerns
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
Failure to robustly capture and record fatal and near-fatal anaphylaxis cases
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. In relation to the Food Standards Agency, the UK Health Security Agency, and the Department of Health and Social Care: • To establish a robust system of capturing and recording cases of anaphylaxes, and specifically, fatal and near-fatal anaphylaxis… • Such a system could involve, mandatory reporting of anaphylaxis presenting to hospital analogous to the current system for notifiable diseases… by 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 allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate public health risk.” ”
Source location
Alexandra Briess · Prevention of Future Deaths report
Page 3 · concerns
Open source report
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
Develop a mechanism for sharing relevant patient-safety anaphylaxis incidents with the UK Fatal Anaphylaxis Registry.

Verbatim wording from the response
“NHS England’s National Patient Safety Team is also working closely with the UK Fatal Anaphylaxis Registry to develop a mechanism for sharing relevant patient safety anaphylaxis incidents with them and this work is ongoing.”

Source location
Response from NHS England
Page 2 · response
Published 14 April 2023
Open published response
21 Nov2022
Avon
Concerns raised1
1. Lack of a robust system for capturing and recording anaphylaxis cases
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.
Actions described in response 8
1. Action
  Update autopsy guidelines for suspected acute anaphylaxis to include UKFAR contact details and direct pathologists to report fatal cases.
  Stated by Royal College of PathologistsStated in progress
2. Action
  Provide governance for the UK Fatal Anaphylaxis Register.
  Stated by The British Society For Allergy & Clinical ImmunologyStated completed
3. Action
  Maintain and improve the UK Fatal Anaphylaxis Register by updating backlog cases, pursuing missing information, and analysing fatal anaphylaxis data.
  Stated by The British Society For Allergy & Clinical ImmunologyStated in progress
1. Action
  Provide dedicated senior research nurse, administrative, and registry-custodian capacity to support register work.
  Stated by The British Society For Allergy & Clinical ImmunologyStated completed
2. Action
  Establish and continue systematic information-sharing links with NHS agencies and other relevant organisations to support register data collection.
  Stated by The British Society For Allergy & Clinical ImmunologyStated in progress
3. Action
  Operate processes for proactively recording UK deaths from anaphylaxis through linked data sources.
  Stated by The British Society For Allergy & Clinical ImmunologyStated completed
4. Action
  Establish the UK Anaphylaxis Registry through the FSA-funded NHS Data project and update its reporting questionnaire with local-authority contact details.
  Stated by Food Standards AgencyStated in progress
5. Action
  Provide funding to update and maintain the UK Fatal Anaphylaxis Register.
  Stated by Food Standards AgencyStated completed
Respondent positions 5
1. Position
  Existing UK-wide processes and linkages are in place to record fatal anaphylaxis deaths and support learning to reduce future deaths.
  Stated by The British Society For Allergy & Clinical ImmunologyExisting arrangements considered sufficient
1. Position
  Ongoing funding for the UK Fatal Anaphylaxis Register is considered a government responsibility because anaphylaxis prevention is a public health issue.
  Stated by The British Society For Allergy & Clinical ImmunologyRedirects responsibility
2. Position
  The register cannot continue its work without further funding after unsuccessful attempts to secure ongoing support.
  Stated by The British Society For Allergy & Clinical ImmunologyUnable to act
3. Position
  Establishing the systems identified by the Coroner falls outside UKHSA’s remit.
  Stated by UK Health Security AgencyOutside remit
4. Position
  Mandatory hospital reporting of anaphylaxis falls within DHSC’s remit and cannot be introduced by the respondent.
  Stated by Food Standards AgencyRedirects responsibility
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.

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
Lack of a robust system for capturing and recording anaphylaxis cases
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
Page 3 · concerns
Open source report
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
Update autopsy guidelines for suspected acute anaphylaxis to include UKFAR contact details and direct pathologists to report fatal cases.

Verbatim wording from the response
“The Royal College of Pathologists is currently updating its autopsy practice guidelines for suspected acute anaphylaxis. The updated guidelines will include contact details for the UKFAR and direct pathologists to report fatal anaphylaxis cases to the UKFAR.”

Source location
Response from Royal College of Pathologists
Page 1 · response
Published 25 November 2022
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
Provide governance for the UK Fatal Anaphylaxis Register.

Verbatim wording from the response
“However BSACI have been collaborating with Manchester Foundation Trust over the past 18 months by providing governance for the UK Fatal Anaphylaxis Register. This register is the only register of its kind in the UK. The aim of the register is to proactively collect data to help us understand the risks and causes of fatal anaphylaxis by analysing the data to determine what the risks of recurrence are, in order to prevent further deaths. Due to the lack of funding previously the register had not been updated since 2005, however in 2020 it was agreed that The British Society for Allergy and Clinical Immunology (BSACI) would provide governance for the register following a one off £100,000 grant from the FSA.”

Source location
Response from British Society for Allergy and Clinical Immunology
Page 2 · response
Published 25 November 2022
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
Maintain and improve the UK Fatal Anaphylaxis Register by updating backlog cases, pursuing missing information, and analysing fatal anaphylaxis data.

Verbatim wording from the response
“While many coroners have called for this function to exist, mechanisms of awareness among those who work in the field has been sub-optimal. The data collection is onerous with in-built delays. Since receiving the funding from FSA, UKFAR has made a concerted effort towards the sole purpose of the grant which was to update the backlog of cases. Due to various recent regulatory changes in data retention, UKFAR has had to update permissions. This led to a re-think and the opportunity to improve liaison with allied agencies based within and outside the NHS which will help reduce existing future such backlogs. However this funding will shortly be running out and after numerous attempts to secure continuous funding from the FSA, we have been informed we have not been successful. We then contacted the DoH directly, however they have not responded to our emails.”

Source location
Response from British Society for Allergy and Clinical Immunology
Page 2 · response
Published 25 November 2022
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
Provide dedicated senior research nurse, administrative, and registry-custodian capacity to support register work.

Verbatim wording from the response
“The grant has allowed investment towards time of a senior research nurse and an administrative assistant contributing 2 sessions each week, payment to ████████ from Allergy Action and to The Office of National Statistics to continue to receiving annual data.”

Source location
Response from British Society for Allergy and Clinical Immunology
Page 3 · response
Published 25 November 2022
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
Establish and continue systematic information-sharing links with NHS agencies and other relevant organisations to support register data collection.

Verbatim wording from the response
“- For best chances of data retrieval, we have focussed our work on the last ten years in the first instance. The data available and analysed thus far has been shared as Appendix 1 of this document - strategic engagement to create links with allied agencies has been successfully made. These are outlined in Appendix 2 of this document.”

Source location
Response from British Society for Allergy and Clinical Immunology
Page 3 · response
Published 25 November 2022
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
Operate processes for proactively recording UK deaths from anaphylaxis through linked data sources.

Verbatim wording from the response
“We have all the processes in place for this system of proactively recording deaths through our web of linkages in the UK which will benefit everyone concerned in learning lessons and attempting to reduce future deaths from anaphylaxis. Our extensive work has repeatedly highlighted the issue of incorrect food labelling resulting in fatal anaphylaxis and we support any initiative taken by the retail industry to improve and clarify these labels to ensure the safety of people with food allergies.”

Source location
Response from British Society for Allergy and Clinical Immunology
Page 4 · response
Published 25 November 2022
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
Establish the UK Anaphylaxis Registry through the FSA-funded NHS Data project and update its reporting questionnaire with local-authority contact details.

Verbatim wording from the response
“The FSA-funded NHS Data project¹ was established to monitor trends in the occurrence of severe, food induced allergic reactions. This work includes the establishment of a UK Anaphylaxis Registry to collect data relating allergic reactions to both food and non-food triggers. While the Registry is not aimed at aiding the investigation of incidents, the questionnaire completed by patients when reporting reactions to the Registry is being updated to includes details on how to contact their local authority’s food safety team to report an incident.”

Source location
Response from Food Standards Agency
Page 3 · response
Published 25 November 2022
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
Provide funding to update and maintain the UK Fatal Anaphylaxis Register.

Verbatim wording from the response
“Additionally In 2021, the FSA provided one-off funding to enable the UK Fatal Anaphylaxis Register (UKFAR) to be updated and maintained. The UKFAR, overseen by the British Society for Allergy and Clinical Immunology, is an active register of deaths from anaphylactic reactions, including food allergies which provides a long-term source of data to improve our understanding of the causes of anaphylaxis related fatalities. This work will help the FSA in its work to reduce numbers of food-related anaphylactic reactions.”

Source location
Response from Food Standards Agency
Page 4 · response
Published 25 November 2022
Open published response
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
Existing UK-wide processes and linkages are in place to record fatal anaphylaxis deaths and support learning to reduce future deaths.

Verbatim wording from the response
“We have all the processes in place for this system of proactively recording deaths through our web of linkages in the UK which will benefit everyone concerned in learning lessons and attempting to reduce future deaths from anaphylaxis. Our extensive work has repeatedly highlighted the issue of incorrect food labelling resulting in fatal anaphylaxis and we support any initiative taken by the retail industry to improve and clarify these labels to ensure the safety of people with food allergies.”

Source location
Response from British Society for Allergy and Clinical Immunology
Page 4 · response
Published 25 November 2022
Open published response
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
Ongoing funding for the UK Fatal Anaphylaxis Register is considered a government responsibility because anaphylaxis prevention is a public health issue.

Verbatim wording from the response
“This is a public health issue and therefore the responsibility of government. So much ground- work has been undertaken with the funding from the FSA, however in order to prevent future deaths from anaphylaxis UKFAR requires on-going funding now.”

Source location
Response from British Society for Allergy and Clinical Immunology
Page 2 · response
Published 25 November 2022
Open published response
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 register cannot continue its work without further funding after unsuccessful attempts to secure ongoing support.

Verbatim wording from the response
“While many coroners have called for this function to exist, mechanisms of awareness among those who work in the field has been sub-optimal. The data collection is onerous with in-built delays. Since receiving the funding from FSA, UKFAR has made a concerted effort towards the sole purpose of the grant which was to update the backlog of cases. Due to various recent regulatory changes in data retention, UKFAR has had to update permissions. This led to a re-think and the opportunity to improve liaison with allied agencies based within and outside the NHS which will help reduce existing future such backlogs. However this funding will shortly be running out and after numerous attempts to secure continuous funding from the FSA, we have been informed we have not been successful. We then contacted the DoH directly, however they have not responded to our emails.”

Source location
Response from British Society for Allergy and Clinical Immunology
Page 2 · response
Published 25 November 2022
Open published response
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
Establishing the systems identified by the Coroner falls outside UKHSA’s remit.

Verbatim wording from the response
“Whilst we understand the seriousness of the failings leading to the death of Celia Marsh responsibility for establishing systems such as those referred to by the Coroner sit outside of the remit of UKHSA.”

Source location
Response UK Health Security Agency
Page 1 · response
Published 25 November 2022
Open published response
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
Mandatory hospital reporting of anaphylaxis falls within DHSC’s remit and cannot be introduced by the respondent.

Verbatim wording from the response
“There are, however, circumstances where no, or no timely, notification is provided. In these cases, a mechanism by which the FSA is made aware of cases of anaphylaxis (fatal or near fatal) would be very helpful. You have suggested a “mandatory reporting of anaphylaxis presenting to hospitals” similar to the system in place for notifiable diseases. The FSA would not be able to introduce such as a system as it would fall within the remit of DHSC.”

Source location
Response from Food Standards Agency
Page 3 · response
Published 25 November 2022
Open published response
18 Dec2020
Inner South London
Concerns raised2
1. Failure to update the WDRP practical guide to address food allergy deaths
2. Delays in notifying food allergy fatalities to relevant food-safety oversight functions
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 2
1. Action
  Develop work to strengthen guidance and support for food businesses.
  Stated by Food Standards AgencyStated in progress
2. Action
  Support the Food Standards Agency’s work to increase information on food-related fatalities.
  Stated by Department of Health and Social CareStated in progress
Respondent positions 1
1. Position
  The mechanism for medical authorities to share suspected food-allergy fatality information is outside the respondent’s policy function.
  Stated by Food Standards AgencyOutside remit
AI-generated summary

Master Ruben Bousquet · 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

Master Ruben Bousquet died after consuming popcorn that had become cross-contaminated with milk protein, causing acute anaphylaxis. The report raised concerns about timely sharing and registration of fatal food-allergy incidents, and about whether food businesses should have access to adrenaline auto-injectors.

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
Failure to update the WDRP practical guide to address food allergy deaths
Wider context from the report
“1. Reporting and Registering The Head of Incidents at the FSA informed the court that the FSA has started work on a reporting platform for allergic reactions, but needs access to information on all fatalities if it is to have effective oversight of food safety. It would welcome improved appropriate sharing of information on fatalities as they are not routinely notified in a timely manner when there is a report of a fatality by the local authority or coroner. The Team Leader of Environmental Health in Royal Borough of Greenwich gave evidence that in 2019 the national Work Related Deaths Committee accepted a recommendation that the practical guide of the WDRP should be updated to address concerns surrounding food allergy deaths and the HSE is considering an amendment, but it has not yet been possible to take this forward. The Head of Trading Standards at the Royal London Borough of Greenwich confirmed that there was no national register (the subject of a PFD report from this jurisdiction in November 2019), but stressed that it is not the HSE who investigates these deaths and that a national process was needed that involved the local authorities coroners and FSA. ”
Source location
Master Ruben Bousquet · Prevention of Future Deaths report
Page 2 · concerns
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
Delays in notifying food allergy fatalities to relevant food-safety oversight functions
Wider context from the report
“1. Reporting and Registering The Head of Incidents at the FSA informed the court that the FSA has started work on a reporting platform for allergic reactions, but needs access to information on all fatalities if it is to have effective oversight of food safety. It would welcome improved appropriate sharing of information on fatalities as they are not routinely notified in a timely manner when there is a report of a fatality by the local authority or coroner. The Team Leader of Environmental Health in Royal Borough of Greenwich gave evidence that in 2019 the national Work Related Deaths Committee accepted a recommendation that the practical guide of the WDRP should be updated to address concerns surrounding food allergy deaths and the HSE is considering an amendment, but it has not yet been possible to take this forward. The Head of Trading Standards at the Royal London Borough of Greenwich confirmed that there was no national register (the subject of a PFD report from this jurisdiction in November 2019), but stressed that it is not the HSE who investigates these deaths and that a national process was needed that involved the local authorities coroners and FSA. ”
Source location
Master Ruben Bousquet · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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
Develop work to strengthen guidance and support for food businesses.

Verbatim wording from the response
“The above comments address the action suggested in your report, but you may wish to know more about the work the FSA undertakes in this area. Food hypersensitivity is a priority for the FSA. We want to improve the quality of life for people living with food hypersensitivity and support them to make safe, informed food choices to effectively manage risk. Our Food Hypersensitivity Programme builds on the FSA’s extensive work over many years on research, recommending legislation to improving labelling, and the provision of information to customers. To date more than 60 projects have been initiated with an investment of £20 million. The FSA also regularly reviews its guidance and support to food businesses and we are developing several pieces of work to strengthen that support.”

Source location
2020-0298-Response-from-Food-Standards-Agency-Redacted
Page 3 · response
Published 8 January 2021
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
Support the Food Standards Agency’s work to increase information on food-related fatalities.

Verbatim wording from the response
“We agree that it is essential that we learn from these tragedies. In conjunction with the FSA’s ongoing programme to collect more information on allergic reactions, the Department of Health and Social Care is working to support the FSA to increase information prevalence regarding such fatalities.”

Source location
2020-0298-Response-from-Dept-for-Health-and-Social-Care-Redacted
Page 1 · response
Published 8 January 2021
Open published response
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 mechanism for medical authorities to share suspected food-allergy fatality information is outside the respondent’s policy function.

Verbatim wording from the response
“notification is provided. In these cases, a mechanism by which the FSA is made aware of the fatality would be very helpful. Most obviously, this might involve the sharing of information with the FSA by medical authorities, but this is not a matter in respect of which the FSA has a policy function.”

Source location
2020-0298-Response-from-Food-Standards-Agency-Redacted
Page 2 · response
Published 8 January 2021
Open published response
30 Sep2019
Inner South London
Concerns raised1
1. Lack of a national register of severe food anaphylactic reactions
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 5
1. Action
  Investigate a reporting platform and related data-sharing arrangements for allergic reactions, including severe non-fatal reactions.
  Stated by Department for Environment, Food & Rural Affairs and Department of Health and Social Care and Food Standards AgencyStated in progress
2. Action
  Increase information about deaths from anaphylactic reactions by identifying access to relevant records for inclusion in the planned reporting platform and analysis.
  Stated by Department for Environment, Food & Rural Affairs and Department of Health and Social Care and Food Standards AgencyStated planned
3. Action
  Respond to the tender for a UK anaphylaxis register in partnership with Imperial College, securing provisional approval.
  Stated by The British Society For Allergy & Clinical ImmunologyStated completed
1. Action
  Explore a sustainable UK Fatal Anaphylaxis Registry operating model and assist in securing adequate funding.
  Stated by The British Society For Allergy & Clinical ImmunologyStated planned
2. Action
  Write to the Food Standards Agency chair to raise the need for funding the UK Fatal Anaphylaxis Registry.
  Stated by The British Society For Allergy & Clinical ImmunologyStated planned
Respondent positions 2
1. Position
  The Food Standards Agency should fund the UK Fatal Anaphylaxis Registry as part of its public-safeguarding responsibility.
  Stated by The British Society For Allergy & Clinical ImmunologyRedirects responsibility
1. Position
  The Food Standards Agency is responsible for allergen legislation, policy and managing national food incidents.
  Stated by National Trading StandardsRedirects responsibility
AI-generated summary

Owen Carey · 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

On 22 April 2017, Owen Carey ate food at Byron restaurant at the O2 centre despite making serving staff aware of his dairy allergy. The chicken contained buttermilk, causing a severe food-induced anaphylactic reaction from which he died. Concerns included the adequacy of allergen training, the prominence and effectiveness of allergen notices and information on menus, and the absence of a national register for severe food anaphylactic reactions.

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
Lack of a national register of severe food anaphylactic reactions
Wider context from the report
“(4) The lack of a national register recording severe food anaphylactic reactions: I was told in evidence that despite faster ambulance response times, a greater awareness of allergies and a greater distribution of epi-pens that the death rate for severe food anaphylaxis remains static and that this is attributed in part to the fact that little is known about these deaths because thus far there has been a failure to collect together any learning from these tragedies. It concerns me that there is therefore no national register recording the circumstances of these deaths which could then be analysed and learnt from by allergy specialists. ”
Source location
Owen Carey · Prevention of Future Deaths report
Page 1 · concerns
Open source report
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
Investigate a reporting platform and related data-sharing arrangements for allergic reactions, including severe non-fatal reactions.

Verbatim wording from the response
“The FSA agrees that there needs to be more systematic information collected on anaphylactic reactions, and that the evidence base is currently inadequate. The FSA is exploring how to collect more data on allergic reactions so that we and others can identify emerging patterns or trends and build a better picture of allergic consumer experience of reactions. We have therefore embarked on work investigating a reporting platform for allergic reactions, including better information on severe reactions that do not result in a death. This is in the early stages as it is likely to involve the development of an online reporting system and/or better data sharing and exchange of information between different organisations.”

Source location
2019-0335-Joint-response-from-FSA-DEFRA-and-DHSC-Redacted
Page 4 · response
Published 10 November 2019
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
Increase information about deaths from anaphylactic reactions by identifying access to relevant records for inclusion in the planned reporting platform and analysis.

Verbatim wording from the response
“The Department of Health and Social Care (DHSC) notes the recommendation on a fatalities register and concurs that it is essential we learn from these tragedies. In conjunction with the FSA’s ongoing programme to collect more information on anaphylactic reactions, DHSC will work to increase information prevalence on these deaths. The Department will identify means of access to relevant records so that they may be included, as is necessary and appropriate in preventing future incidents, within the FSA’s planned reporting platform and purposes of analysis. In addition to this the Department wishes to underline its emphatic support of the FSA’s strategy on food hypersensitivity.”

Source location
2019-0335-Joint-response-from-FSA-DEFRA-and-DHSC-Redacted
Page 4 · response
Published 10 November 2019
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
Respond to the tender for a UK anaphylaxis register in partnership with Imperial College, securing provisional approval.

Verbatim wording from the response
“early warning signal for new risks and highlight specific situations where risk is higher so that they can be actively mitigated. Such a registry already exists in Europe and the Food Standards Agency has recently issued a tender for a UK centre to operate a UK register for anaphylaxis, which will also feed into the wider European platform already in operation. The BSACI, in partnership with Imperial College, have responded to this call and have received provisional approval.”

Source location
2019-0335-Response-by-BSACI
Page 2 · response
Published 10 November 2019
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
Explore a sustainable UK Fatal Anaphylaxis Registry operating model and assist in securing adequate funding.

Verbatim wording from the response
“As a consequence, earlier this year, the current allergy team at Manchester University hospitals (who are the custodians of the data) entered into conversations with the BSACI to explore the possibility of closer working in order to find a solution to the sustainability of the UKFAR. Following from this, BSACI council made a commitment to explore this further including consideration of a workable operating model and assistance in raising adequate funding, thought to be around £120,000 annually. Whilst funding streams could include charitable donations or industry support, these carry significant risk and the involvement of industry may be perceived to taint the integrity of the outputs. The BSACI believe that the appropriate funding solution would be for the Foods Standards Agency to support the UKFAR, as part of their responsibility to safeguarding the public.”

Source location
2019-0335-Response-by-BSACI
Page 2 · response
Published 10 November 2019
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
Write to the Food Standards Agency chair to raise the need for funding the UK Fatal Anaphylaxis Registry.

Verbatim wording from the response
“This would ensure sustainability and also aid engagement with the coronary system, which UKFAR relies on to provide details of all cases of suspected fatal anaphylaxis. The BSACI directors will be writing to the chair of the FSA to raise this issue, which had been previously highlighted but not led to any offer of funding.”

Source location
2019-0335-Response-by-BSACI
Page 2 · response
Published 10 November 2019
Open published response
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 Food Standards Agency should fund the UK Fatal Anaphylaxis Registry as part of its public-safeguarding responsibility.

Verbatim wording from the response
“As a consequence, earlier this year, the current allergy team at Manchester University hospitals (who are the custodians of the data) entered into conversations with the BSACI to explore the possibility of closer working in order to find a solution to the sustainability of the UKFAR. Following from this, BSACI council made a commitment to explore this further including consideration of a workable operating model and assistance in raising adequate funding, thought to be around £120,000 annually. Whilst funding streams could include charitable donations or industry support, these carry significant risk and the involvement of industry may be perceived to taint the integrity of the outputs. The BSACI believe that the appropriate funding solution would be for the Foods Standards Agency to support the UKFAR, as part of their responsibility to safeguarding the public.”

Source location
2019-0335-Response-by-BSACI
Page 2 · response
Published 10 November 2019
Open published response
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 Food Standards Agency is responsible for allergen legislation, policy and managing national food incidents.

Verbatim wording from the response
“It seems however that the concerns you raise relate to the underpinning statutory system, in particular the lack of statutory requirements in relation to the notification of allergens in the circumstances that Mr Carey purchased his food and also the lack of a national register of such incidents. I see that your letter was also sent to the Food Standards Agency. The FSA have the responsibility, on behalf of Government, for the legislation and policy relating to allergens and for managing national food incidents so I am sure they will be well placed to address the issues you have raised.”

Source location
2019-0335-Response-by-National-Trading-Standards
Page 2 · response
Published 10 November 2019
Open published response
4 Jan2018
South Yorkshire (Western)
Concerns raised1
1. Lack of procedures for reporting anaphylaxis incidents at commercial food premises to Trading Standards
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Add greater emphasis to reporting near misses and food-allergy deaths in the Practice Guidance.
  Stated by Food Standards AgencyStated planned
2. Action
  Review and update the draft anaphylaxis protocol, including a Trading Standards referral form and communication algorithm.
  Stated by Barnsley Hospital NHS Foundation TrustStated completed
3. Action
  Submit the draft protocol for Clinical Business Unit Governance Meeting review and ratification, then forward the agreed final protocol.
  Stated by Barnsley Hospital NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  The Department of Health and Social Care will respond regarding measures to be put in place at a local level.
  Stated by Food Standards AgencyRedirects responsibility
AI-generated summary

Dylan Paul Hill · 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

Dylan Paul Hill died after eating a korma meal containing almond powder contaminated with peanuts at a restaurant in Barnsley, causing an anaphylactic reaction. The report identified concerns about allergen information, ingredient checking and labelling at food premises, and the absence of procedures for reporting non-fatal anaphylactic reactions to Trading Standards and other regulatory authorities.

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
Lack of procedures for reporting anaphylaxis incidents at commercial food premises to Trading Standards
Wider context from the report
“Evidence was given before the Court of an incident within the same premises in September 2014 where a curry containing nuts was given to a customer who had requested a nut free curry. That customer had an anaphylactic reaction and was taken to hospital where he made a full recovery. Evidence was also given that the Trading Standards department of the local council had not been told of this incident prior to the death of Mr Hill. Had they known, they would have arranged a priority visit. After Mr Hill's death the restaurant were issued a prohibition notice that they were not permitted to offer allergen free meals. Evidence was given that there are no procedures in place for such communications between the health services and Trading Standards in cases of non fatal anaphylactic reactions. In my opinion there is a risk that future deaths may occur unless cases of non fatal anaphylactic reactions caused by the ingestion of purchases from food business operatives are reported to those regulatory authorities responsible for the supervision and monitoring of food safety and hygiene. The question therefore arises as to whether the emergency services and health services within the area can work together to ensure that Trading Standards Departments are made aware of all anaphylaxis incidents relating to commercial premises so that the appropriate action can be taken as regards those premises. ”
Source location
Dylan Paul Hill · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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
Add greater emphasis to reporting near misses and food-allergy deaths in the Practice Guidance.

Verbatim wording from the response
“more emphasis on reporting of near misses and deaths from food allergy in the Practice Guidance. We will also be writing to local authorities to highlight lessons learnt, and reinforce our expectations on good allergen management practices.”

Source location
2018-0004-Response-by-Food-Standards-Agency
Page 2 · response
Published 7 March 2018
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
Review and update the draft anaphylaxis protocol, including a Trading Standards referral form and communication algorithm.

Verbatim wording from the response
“Our anaphylaxis draft protocol has been reviewed and updated in accordance with our internal governance processes (see enclosure 1).”

Source location
2018-0004-Response-by-Barnsley-Hospital-NHS-Trust
Page 1 · response
Published 7 March 2018
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
Submit the draft protocol for Clinical Business Unit Governance Meeting review and ratification, then forward the agreed final protocol.

Verbatim wording from the response
“The draft protocol will be taken to the Trust’s Clinical Business Unit Governance Meeting on 23 March 2018 for it to be reviewed and ratified we will forward you the final protocol when this has been agreed.”

Source location
2018-0004-Response-by-Barnsley-Hospital-NHS-Trust
Page 2 · response
Published 7 March 2018
Open published response
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 Department of Health and Social Care will respond regarding measures to be put in place at a local level.

Verbatim wording from the response
“I am saddened to hear about the death of Mr Hill, and my thoughts are with his friends and family. We are aware that the Department of Health and Social Care will be responding to you regarding measures to be put in place at a local level.”

Source location
2018-0004-Response-by-Food-Standards-Agency
Page 1 · response
Published 7 March 2018
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised3

Failure to mandate referral of fatal anaphylaxis cases

Lack of a national reporting and fatality-register system for anaphylaxis

Failure to robustly capture and record fatal and near-fatal anaphylaxis cases

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

Concerns raised1

Lack of a robust system for capturing and recording anaphylaxis cases

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.8

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5

Concerns raised2

Failure to update the WDRP practical guide to address food allergy deaths

Delays in notifying food allergy fatalities to relevant food-safety oversight functions

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of a national register of severe food anaphylactic reactions

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.5

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Actions described in response 1

Actions described in response 8

Respondent positions 5

Actions described in response 2

Respondent positions 1

Actions described in response 5

Respondent positions 2