10 Sep 2025 Stuart GILCHRIST · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 1 Failure to make restaurants and food establishments aware of choking-rescue equipment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Stuart GILCHRIST · 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
Stuart GILCHRIST, aged 77, died after choking on food at a restaurant during an outing with care home staff and other service users. Despite prompt first aid, emergency treatment and CPR, he was declared deceased. The principal concern was that restaurants and food establishments may not be aware of, or have access to, LifeVac-type suction devices that may assist during choking incidents.
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. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to make restaurants and food establishments aware of choking-rescue equipment
Wider context from the report “1. During the evidence it was heard that there is a device that may assist in incidents of choking, it was referred to as a LifeVac (this may be a trade name). The care staff member, had recognised that Mr GILCHRIST was choking and while administering assistance to him had the foresight to ask if the restaurant had a “LifeVac” style device.
2. It was acknowledged during the inquest that restaurants have first aid items and some may have equipment such as a defibrillator however they may not be aware that this useful item exists, nor that it is relatively inexpensive.
3. At the time the evidence was heard, I was unaware of who would be responsible for advising restaurants and food establishments of the availability of such an item, or to raise with those outlets its usefulness should a customer begin to choke ; so therefore this RPFD is sent to three organisations who may have varying levels of responsibility - without restaurants and food establishments being made aware of such an item, they may not think to purchase one and retain it within their first aid armoury .
4. I also appreciate that LifeVac is probably a trade name and I only use it to describe the type of item that would be deemed useful.
” Open source report
19 Jan 2024 DAVID CHARLES MITCHENER · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3 Potentially very serious risks and side effects from excessive vitamin supplement intake View source Absence of appropriate dosage warnings and guidance for vitamin supplements View source Food labelling requirements failing to require warnings about risks and side effects on packaging View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
DAVID CHARLES MITCHENER · 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
David Mitchener was admitted to East Surrey Hospital with hypercalcaemia on 10 May 2023 and died there on 20 May 2023. The substantive concerns were the potentially serious risks of excessive vitamin supplement use, the absence of appropriate dosage guidance and warnings, and food labelling requirements that did not require these risks to be stated on the packaging.
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. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Potentially very serious risks and side effects from excessive vitamin supplement intake
Wider context from the report “(1) Vitamin supplements can have potentially very serious risks and side effects when taken in excess
(2) Current food labelling requirements do not require these risks and side effects to be written on the packaging.
(3) Absence of appropriate warnings and guidance about dosage
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Absence of appropriate dosage warnings and guidance for vitamin supplements
Wider context from the report “(1) Vitamin supplements can have potentially very serious risks and side effects when taken in excess
(2) Current food labelling requirements do not require these risks and side effects to be written on the packaging.
(3) Absence of appropriate warnings and guidance about dosage
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Food labelling requirements failing to require warnings about risks and side effects on packaging
Wider context from the report “(1) Vitamin supplements can have potentially very serious risks and side effects when taken in excess
(2) Current food labelling requirements do not require these risks and side effects to be written on the packaging.
(3) Absence of appropriate warnings and guidance about dosage
” 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 Contact relevant local authorities to ascertain whether the product complies with food supplement requirements.
Verbatim wording from the response “The FSA will raise your report at the next cross-government Food Supplements Working Group, which will take place in April, and we will ensure full consideration will be given to the matters of concern you have highlighted. We intend to contact the relevant local authorities to ascertain whether the product is in compliance with food supplements requirements. We would be grateful if you could share any product details or packaging that you have, which will inform and aid our interactions with the relevant local authorities.” Source location Response from Food Standard Agency
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 Amending key supplement legislation is assigned to Ministers in the respective nations.
Verbatim wording from the response “relation to England, we understand that DHSC is providing a response in respect to their policy. Powers to amend the key legislation in this area sits with Ministers in the respective nations. Co-ordination of policy takes place through a number of groups including the Food Supplements Working Group, which the FSA chairs.” Source location Response from Food Standard Agency
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 Policy advice on supplement composition and labelling in England is assigned to the Department of Health and Social Care.
Verbatim wording from the response “The composition and labelling of supplements is devolved and policy advice to Ministers on it rests with a number of different bodies which includes the Department for Health and Social Care (DHSC) in England, Welsh Government, the FSA in Wales and Northern Ireland, and with Food Standards Scotland in Scotland. As your report is in” Source location Response from Food Standard Agency
Open published response
9 Aug 2023 Rohan GODHANIA · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 3 Lack of guidance for testing ammonia levels in patients presenting in extremis with an unknown cause View source Lack of clarity and consistent guidance for classifying teenagers aged 16-18 as paediatric patients or adults View source Failure of high-protein supplement and drink labels to provide adequate warnings and safety information for people with urea cycle disorders View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Rohan GODHANIA · 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
Rohan GODHANIA became unwell after consuming a high-protein drink on 15 August 2020, was admitted to hospital, and died on 18 August 2020 from Ornithine Transcarbamylase Deficiency. The report identifies concerns about inconsistent NHS classification of teenagers aged 16–18 and a lack of emergency-department guidance on ammonia testing for patients presenting in extremis with an unknown cause.
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. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for testing ammonia levels in patients presenting in extremis with an unknown cause
Wider context from the report “2. Guidance for Testing for Ammonia in Emergency Departments
The other concerning issue that requires immediate attention is the lack of guidance for testing ammonia levels in patients who present in extremis with an unknown cause . Timely and accurate diagnosis is essential in such cases to ensure appropriate treatment and prevent unnecessary deaths. The guideline should include clear protocols for conducting ammonia tests, interpreting the results and making informed clinical decisions based on the findings. The guidance should be disseminated to all emergency departments and healthcare facilities.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity and consistent guidance for classifying teenagers aged 16-18 as paediatric patients or adults
Wider context from the report “1. Age classification of Teenagers 16-18 within the NHS
There seems to be a lack of clarity and consistent guidance across the NHS regarding the appropriate classification of teenagers aged 16-18. The question of whether they should be treated as paediatric patients or adults is leading to confusion and potential disparities in the care provided. I consider that this should be urgently reviewed by NHS England and if necessary the guidance on age classification updated ensuring that all healthcare providers adhere to a unified approach emphasising the importance of consistent and appropriate care for this age group.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure of high-protein supplement and drink labels to provide adequate warnings and safety information for people with urea cycle disorders
Wider context from the report “High protein supplements and drinks are easily accessible to the general public, yet their labels fail to adequately inform consumers about the potential dangers posed to individuals with urea cycle disorders, such as Ornithine Transcarbamylase (OTC) deficiency . This genetic disorder can lead to severe medical emergencies, requiring immediate medical intervention to prevent life-threatening complications. This disorder can be triggered by the sudden increased ingestion of protein.
Consideration should be given as to whether the labels should prominently display a warning about the potential risks for individuals with an undiagnosed urea cycle disorder and include clear and concise information on symptoms of this and the importance of seeking immediate medical advice .
” 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 Share the coroner’s report with DHSC to support consideration of additional food labelling.
Verbatim wording from the response “As noted above, nutritional and broader health advice on whether and how it could be included on labelling is the responsibility of DHSC in England. We will share your report with DHSC so that they can more fully consider your recommendation for additional labelling.
It may also be worth you writing to them directly, copied to DEFRA as the department responsible for food compositional standards and labelling” Source location Response from Food Standards Agency
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 Responsibility for food compositional standards and labelling rests with DEFRA in England.
Verbatim wording from the response “The FSA has responsibility for food and feed safety and hygiene in England and Wales, food compositional standards and labelling policy in Northern Ireland and Wales, and nutritional health claims and nutritional labelling in Northern Ireland.
In England responsibility for food compositional standards and labelling policies rests with the Department of Environment, Food and Rural Affairs (DEFRA).
Nutritional health claims and nutritional labelling responsibility rests with the Department of Health and Social Care (DHSC) in England and the Welsh Government in Wales.” Source location Response from Food Standards Agency
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 Responsibility for nutritional and broader health advice on additional food labelling rests with DHSC in England.
Verbatim wording from the response “The FSA has responsibility for food and feed safety and hygiene in England and Wales, food compositional standards and labelling policy in Northern Ireland and Wales, and nutritional health claims and nutritional labelling in Northern Ireland.
In England responsibility for food compositional standards and labelling policies rests with the Department of Environment, Food and Rural Affairs (DEFRA).
Nutritional health claims and nutritional labelling responsibility rests with the Department of Health and Social Care (DHSC) in England and the Welsh Government in Wales.” Source location Response from Food Standards Agency
Open published response
21 Nov 2022 Celia Lindsey MARSH · Prevention of Future Deaths report Avon
View report summary
Concerns raised 12 Potentially unsafe exposure to undeclared allergens for people at significantly higher risk of fatal reactions View source Potentially misleading food-labelling wording and public understanding of allergen absence View source Lack of a robust system for capturing and recording anaphylaxis cases View source Failure to obtain and preserve stomach contents and tissue samples at post-mortem examination View source Lack of adequate education for doctors and patients in anaphylaxis risk groups View source Delays in raising suspected anaphylaxis deaths with the Senior Coroner View source Lack of robust confirmation of allergen absence in ingredients and production View source Outdated pathology guidance for suspected anaphylaxis deaths View source Lack of a standard protocol for timely and appropriate sampling in suspected anaphylaxis deaths View source Failure to retain hospital blood samples in suspected anaphylaxis cases View source Failure to prioritise post-mortem examinations in suspected anaphylaxis deaths View source Failure to obtain and store an early post-death blood sample for later analysis View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Potentially unsafe exposure to undeclared allergens for people at significantly higher risk of fatal reactions
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group .
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Potentially misleading food-labelling wording and public understanding of allergen absence
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;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Food Standards Agency; that does not assign responsibility.
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;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and preserve stomach contents and tissue samples at post-mortem examination
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;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate education for doctors and patients in anaphylaxis risk groups
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;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Delays in raising suspected anaphylaxis deaths with the Senior Coroner
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;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of robust confirmation of allergen absence in ingredients and production
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim .
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Outdated pathology guidance for suspected anaphylaxis deaths
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;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of a standard protocol for timely and appropriate sampling in suspected anaphylaxis deaths
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;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to retain hospital blood samples in suspected 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;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise post-mortem examinations in suspected anaphylaxis deaths
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;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and store an early post-death blood sample for later analysis
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;
” 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 Consult on the updated allergen technical guidance concerning precautionary allergen and free-from statements.
Verbatim wording from the response “We are in the process of updating our allergen technical guidance to say that precautionary allergen statements should not be used in combination with a ‘free from’ statement for the same allergen. This work is ongoing and will be put out for further consultation shortly.” Source location Response from Food Standards Agency
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
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
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 Consider how best to promote current guidance to businesses producing foods with free-from and vegan claims.
Verbatim wording from the response “We will consider how best to promote the current guidance to businesses producing foods with these claims to encourage best practice more widely and continue to consider it alongside our work on precautionary allergen labelling.” Source location Response from Food Standards Agency
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 Update allergen technical guidance to discourage combining precautionary allergen statements with same-allergen free-from statements.
Verbatim wording from the response “We are in the process of updating our allergen technical guidance to say that precautionary allergen statements should not be used in combination with a ‘free from’ statement for the same allergen. This work is ongoing and will be put out for further consultation shortly.” Source location Response from Food Standards Agency
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 Pathology policy responsibility lies with DHSC and the Royal College of Pathologists, rather than the respondent.
Verbatim wording from the response “Your concerns regarding pathology have been noted, however this is not an area where the FSA has policy responsibility. I can see that your report has been directed to the Department for Health and Social Care (DHSC) and the Royal College of Pathologists who may be able to offer a response to these concerns. We are however, open to assisting other government departments where we can.” Source location Response from Food Standards Agency
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
Open published response
18 Dec 2020 Master Ruben Bousquet · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Failure to update the WDRP practical guide to address food allergy deaths View source Delays in notifying food allergy fatalities to relevant food-safety oversight functions View source Absence of a national process and register for food allergy deaths View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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. The report was sent to Food Standards Agency; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Food Standards Agency; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Absence of a national process and register for 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 .
” 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
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 a national register of food-allergy fatalities is outside the respondent’s remit because of other bodies’ medical and clinical responsibilities.
Verbatim wording from the response “• Separately, whilst it is not within FSA’s remit to establish a national register of fatalities, given their medical and clinical responsibilities in this area, we are discussing with the Department for Health and Social Care (DHSC) how we could analyse and evaluate different data sources to give us a clearer picture of allergic reactions that result in fatality.” Source location 2020-0298-Response-from-Food-Standards-Agency-Redacted
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
Open published response
30 Sep 2019 Owen Carey · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 5 Lack of statutory requirements for the appearance of restaurant allergen notices View source Lack of complete allergen information on the face of restaurant menus View source Lack of a national register of severe food anaphylactic reactions View source Inadequate allergen training for serving staff View source Insufficient prominence of allergen notices on restaurant menus View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of statutory requirements for the appearance of restaurant allergen notices
Wider context from the report “(2) The effectiveness of the current placement and appearance of allergen notices on restaurant menus to trigger an allergen discussion between a customer and serving staff: I was told, and accept, that it was more important to trigger a discussion between a customer and member of serving staff about allergens than to have a menu which included complete allergen information on its face. However, the prompt for this discussion on the Byron O2 menu at the time was: (i) on the side of the menu which appeared to focus solely on a ‘special’, namely a Kim Cheese burger, (ii) at the very bottom and distant from all the main food options, (iii) in very small font and (iv) on a royal blue background in black ink. I was told that this placement and appearance was not outwith the ‘general approach of the restaurant industry as a whole and that the current Food Information Regulations did not, unlike with prepacked food, specify the location and / or font size and / or prominence of such an allergen notice. It concerns me that such little prominence appears to be given industry wide to a notice which is intended to trigger what could potentially be a lifesaving discussion between a customer and member of serving staff. It further concerns me that there are no statutory requirements regarding the appearance of such an allergy notice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of complete allergen information on the face of restaurant menus
Wider context from the report “(3) The lack of key allergen information on the face of restaurant menus and therefore their potential to be falsely reassuring: In my findings I concluded that Owen and his brother would have been falsely reassured with the menu description of Owen's order because on its face the Byron O2 menu in place at the time did not readily identify that the chicken would have been marinated in buttermilk or at all. I was shown a more up to date menu from Byron O2 and note that where buttermilk is now used to marinate chicken it is identified. However, the prompt for this change was one of ‘food fashion’ I was told rather than a move to make the menu more allergen friendly. Although I accept that triggering a discussion between a customer and member of serving staff about allergens is of key importance (as indicated above), the absence of any simple allergen words or symbols on the face of a restaurant menu is of concern , particularly when one takes into account (i) what I was told about the latest figures demonstrating how a significant proportion of customers may be naturally shy/ reluctant about sharing their allergies with serving staff and (ii) that restaurants, like Byron O2, tend to attract younger diners dining alone (i.e. school age children without their parents). It also concerns me that at the time there were symbols on the menu depicting the use of peanuts, but not other allergen , which in my view could also have potentially falsely reassured diners that allergens were being identified on the face of the menu when in fact they were not .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Food Standards Agency; that does not assign responsibility.
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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Inadequate allergen training for serving staff
Wider context from the report “(1) The adequacy and effectiveness of allergen training at Byron O2: My findings included that there must have been a human error by a member of Byron O2 serving staff at the point of ordering. The training provided to serving staff regarding allergens at Byron O2 was limited to a combination of staff members simply attesting to the fact that they had read the company's training on allergen information and no more, coupled with an “on the job” induction in respect of which no records or details existed. It was accepted in evidence that Byron O2 had a high turnover of serving staff. This, I was told and accept, is common for the restaurant industry overall, who often rely, for example on seasonal workers. I was not confident that the current approach to allergen training about which I heard evidence was effective and / or would engage the less diligent employee , which any organisation will have, and which are potentially in a greater proportion where there is high staff turnover.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Insufficient prominence of allergen notices on restaurant menus
Wider context from the report “(2) The effectiveness of the current placement and appearance of allergen notices on restaurant menus to trigger an allergen discussion between a customer and serving staff: I was told, and accept, that it was more important to trigger a discussion between a customer and member of serving staff about allergens than to have a menu which included complete allergen information on its face. However, the prompt for this discussion on the Byron O2 menu at the time was: (i) on the side of the menu which appeared to focus solely on a ‘special’, namely a Kim Cheese burger, (ii) at the very bottom and distant from all the main food options, (iii) in very small font and (iv) on a royal blue background in black ink. I was told that this placement and appearance was not outwith the ‘general approach of the restaurant industry as a whole and that the current Food Information Regulations did not, unlike with prepacked food, specify the location and / or font size and / or prominence of such an allergen notice. It concerns me that such little prominence appears to be given industry wide to a notice which is intended to trigger what could potentially be a lifesaving discussion between a customer and member of serving staff. It further concerns me that there are no statutory requirements regarding the appearance of such an allergy notice.
” Open source report
Concerns raised 1 Lack of procedures for reporting anaphylaxis incidents at commercial food premises to Trading Standards View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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. The report was sent to Food Standards Agency; that does not assign responsibility.
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.
” 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
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
Open published response
22 Jun 2017 Linda Jean BARANOWSKI · Prevention of Future Deaths report Hertfordshire
View report summary
Concerns raised 1 Continued sale and wide availability of slimming products capable of causing serious inflammatory harm View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Linda Jean BARANOWSKI · 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
Linda Baranowski was admitted to hospital with abdominal pain, collapse, skin discolouration and multi-organ failure, and died on 25 February 2016 after treatment at several hospitals. The inquest identified an inflammatory response potentially linked to one or more dietary supplements, including slimming tablets, tea and body cream; the hot slimming cream was highlighted as likely to have contributed. The report noted that these products and similar products remained widely available.
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. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Continued sale and wide availability of slimming products capable of causing serious inflammatory harm
Wider context from the report “The medical opinion at the inquest was that Linda Baranowski died as a result of ingesting or applying one, or a combination, of the following:
• T5 diet strongest fat burner legal 30 capsules slimming weight loss pills detox
• Slimming Chinese Green Tea weight loss detox burn fat herbal 30 bags
• Hot Anti-Cellulite Balo slimming cream gel, chill 85ml helps burn fast
• Himalayan Premium Green Tea pyramid bags
Whilst I acknowledge that the precise effect of these supplements is not known, the role of the hot slimming cream in particular was highlighted by the consultant at the Specialist Burns Centre as being likely to have contributed to the fatal inflammatory response. It is my understanding that these products, and many products of a similar nature, are still on sale and widely available.
” Open source report
29 Sep 2014 Tiya Chetan Chauhan · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 3 Lack of awareness of the choking risks of raw jelly cubes during play View source Absence of choking-risk warnings on packets of raw jelly View source Insufficient supervision of raw jelly play with young children View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tiya Chetan Chauhan · 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
Tiya Chetan Chauhan died on 24 August 2012 at St George’s Hospital after inhaling a cube of raw jelly that obstructed her airway during a sensory tray activity at a nursery. The report identified concerns about the choking risk of raw jelly cubes, inadequate supervision, insufficient risk assessment, and the absence of warnings on packets of raw jelly.
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. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of the choking risks of raw jelly cubes during play
Wider context from the report “(1) That nurseries, other childcare and school settings and even parents may be using raw jelly during play without appreciating the especial risks of choking that a cube of raw jelly presents .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Absence of choking-risk warnings on packets of raw jelly
Wider context from the report “(2) That packets of raw jelly do not contain a warning that cubes of jelly present a choking risk to children .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Food Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Insufficient supervision of raw jelly play with young children
Wider context from the report “(3) That raw jelly cubes may be used in play with young children without sufficient supervision .
” 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 Forward information about raw jelly cube risks to UK local authority environmental health services for consideration during routine food safety inspections.
Verbatim wording from the response “With regard to your first point, and alerting nurseries and other childcare settings about the issue, I understand that Ofsted intend to include specific information on the incident in their next newsletter to local authority Directors of Children’s Services. This will highlight the particular risks associated with raw jelly cubes in childcare and school settings. The FSA will separately forward this information to UK local authority environmental health services, to similarly highlight the risks so that environmental health officers are able to consider them during their routine food safety inspections of these establishments.” Source location 2014-0575-Response-by-Food-Standards-Agency
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 Copy the report and concerns about raw jelly cubes to relevant Department of Health officials for consideration in early-years food advice to parents.
Verbatim wording from the response “I note your reference to parents being made aware of the risks associated with raw jelly cubes. A number of specialist websites for parents or carers did highlight this issue following the incident. Problems associated with food choking hazards is also something included in relevant NHS information. However, I will ensure your report and your specific concerns about raw jelly cubes is copied to relevant officials in the Department of Health for their consideration in relation to early years food advice to parents.” Source location 2014-0575-Response-by-Food-Standards-Agency
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 contact with Ofsted and provide relevant food safety information during its process of disseminating understanding of raw jelly cube risks.
Verbatim wording from the response “I am aware that Ofsted will be liaising with the Local Government Association over what more can be done to disseminate understanding of this issue, and the FSA will maintain contact with Ofsted during this process to provide any relevant food safety information.” Source location 2014-0575-Response-by-Food-Standards-Agency
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 Forward the report to relevant food manufacturing and retail trade bodies for information and consideration regarding warnings about raw jelly cube risks.
Verbatim wording from the response “In relation to your concerns over the lack of warning about the issue on packaging, the FSA will forward a copy of your report to relevant industry manufacturing and retail trade bodies, for their information and consideration. I can confirm that there is no specific legal requirement (in what is an area of law closely harmonised at EU level) for such food to contain a warning on the label or on a point of sale notice if sold loose. However, this is something that a particular manufacturer or retailer” Source location 2014-0575-Response-by-Food-Standards-Agency
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 There is no specific legal requirement to require warnings on packaging or loose-food point-of-sale notices; manufacturers and retailers may act voluntarily.
Verbatim wording from the response “In relation to your concerns over the lack of warning about the issue on packaging, the FSA will forward a copy of your report to relevant industry manufacturing and retail trade bodies, for their information and consideration. I can confirm that there is no specific legal requirement (in what is an area of law closely harmonised at EU level) for such food to contain a warning on the label or on a point of sale notice if sold loose. However, this is something that a particular manufacturer or retailer” Source location 2014-0575-Response-by-Food-Standards-Agency
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations