6 Apr 2023 Alexandra Briess · Prevention of Future Deaths report Berkshire
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Concerns raised 9 Barriers to information sharing about deceased anaphylaxis patients View source Failure to mandate referral of fatal anaphylaxis cases View source Inadequate immediate investigation of suspected anaphylaxis deaths View source Lack of a national reporting and fatality-register system for anaphylaxis View source Lack of named accountability for allergy services and provision View source Lack of a clear UKFAR referral requirement after unsuccessful resuscitation View source Failure to robustly capture and record fatal and near-fatal anaphylaxis cases View source Insufficient funding for anaphylaxis data gathering and research View source Lack of national leadership for anaphylaxis work View source See 6 more concerns
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Alexandra Briess · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alexandra Briess underwent tonsillectomy, later required surgery for post-operative bleeding, and suffered sudden deterioration and cardiac arrest during anaesthesia on 30 May 2021. She died on 31 May 2021, with the most likely cause identified as an anaphylactic reaction to Rocuronium; there were no concerns about her clinical management. The principal concerns were the lack of national leadership and funding for anaphylaxis work, mandatory reporting of fatal anaphylaxis, and improved national data gathering, research and information sharing.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to UK Fatal Anaphylaxis Registry; that does not assign responsibility.
PFD Monitor interpretation Barriers to information sharing about deceased anaphylaxis patients
Wider context from the report “5. Information sharing amongst the organisations referred to in this report should be straightforward . Confidentiality constraints are important, but not the same in the case of a deceased person as they are for a living person . I believe that a confidential advisory group has already started to consider this matter.
” 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 UK Fatal Anaphylaxis Registry; that does not assign responsibility.
PFD Monitor interpretation Failure to mandate referral of fatal anaphylaxis cases
Wider context from the report “It seems clear to all coroners in these cases, and those involved in this area of medical expertise, that the only way to improve understanding and prevent or reduce future deaths is to gather information nationally and fund appropriate research.
Appropriate organisations already exist, and there is a lot of goodwill towards improving understanding in this area. It does however require national leadership and “joining up” of these organisations.
1. I have tried to make my list of issues clear and succinct. Paragraph 2 below sets out the crux of this ongoing risk.
2. There is significant goodwill and desire to improve amongst numerous organisations involved in anaphylaxis work. What is lacking is national leadership and funding. In my view, consideration should be given to creating a leadership role and responsibility within NHS England to coordinate a national approach.
3. As considered by other coroners before me, it should be mandatory to refer fatal anaphylaxis cases . UKFAR has indicated that they would be prepared to take on the role of receiving these reports (to avoid duplication for reporting clinicians), with the responsibility to forward the relevant information to other organisations such as the MHRA, where appropriate. Whilst my focus is on fatal anaphylaxis, inclusion of non-fatal cases would be a matter for the lead role to consider.
4. Gathering data and using this to research and reduce the risk of future deaths requires funding, and this should be reviewed.
” 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 UK Fatal Anaphylaxis Registry; that does not assign responsibility.
PFD Monitor interpretation Inadequate immediate investigation of 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 .
In relation to the Food Standards Agency, the UK Health Security Agency, and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxes, and specifically, fatal and near-fatal anaphylaxis…
• Such a system could involve, mandatory reporting of anaphylaxis presenting to hospital analogous to the current system for notifiable diseases… by registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the State of Victoria in Australia, and allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate public health risk.”
” 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 UK Fatal Anaphylaxis Registry; that does not assign responsibility.
PFD Monitor interpretation Lack of a national reporting and fatality-register system for anaphylaxis
Wider context from the report ““In my opinion action should be taken to consider establishing a national reporting system which includes timely reporting to local authority and FSA and maintenance of a register of fatalities and their investigations , and consideration be given to investigating the feasibility of wider access to AAI’s. I believe that the organizations would wish to learn of the circumstances of this death and are in a position to facilitate a collaborative process to mitigate or prevent future deaths.”
” 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 UK Fatal Anaphylaxis Registry; that does not assign responsibility.
PFD Monitor interpretation Lack of named accountability for allergy services and provision
Wider context from the report ““The issues within this Prevention of Future Deaths report are predominantly national issues, but I heard at inquest that there is no person with named accountability for allergy services and allergy provision at NHS England, or the Department of Health as a whole .”
” 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 UK Fatal Anaphylaxis Registry; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear UKFAR referral requirement after unsuccessful resuscitation
Wider context from the report “6. Consideration of including contact details for the UKFAR in algorithms used by doctors attempting to resuscitate patients – so that there is a clear requirement for referral to UKFAR in the event of an unsuccessful resuscitation . This is currently being considered by the Resuscitation Council UK.
” 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 UK Fatal Anaphylaxis Registry; that does not assign responsibility.
PFD Monitor interpretation Failure to robustly capture and record fatal and near-fatal anaphylaxis cases
Wider context from the report ““Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this, changes are required.
In relation to the Food Standards Agency, the UK Health Security Agency, and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxes, and specifically, fatal and near-fatal anaphylaxis …
• Such a system could involve, mandatory reporting of anaphylaxis presenting to hospital analogous to the current system for notifiable diseases… by registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the State of Victoria in Australia, and allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate public health risk.”
” 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 UK Fatal Anaphylaxis Registry; that does not assign responsibility.
PFD Monitor interpretation Insufficient funding for anaphylaxis data gathering and research
Wider context from the report “It seems clear to all coroners in these cases, and those involved in this area of medical expertise, that the only way to improve understanding and prevent or reduce future deaths is to gather information nationally and fund appropriate research.
Appropriate organisations already exist, and there is a lot of goodwill towards improving understanding in this area. It does however require national leadership and “joining up” of these organisations.
1. I have tried to make my list of issues clear and succinct. Paragraph 2 below sets out the crux of this ongoing risk.
2. There is significant goodwill and desire to improve amongst numerous organisations involved in anaphylaxis work. What is lacking is national leadership and funding. In my view, consideration should be given to creating a leadership role and responsibility within NHS England to coordinate a national approach.
3. As considered by other coroners before me, it should be mandatory to refer fatal anaphylaxis cases. UKFAR has indicated that they would be prepared to take on the role of receiving these reports (to avoid duplication for reporting clinicians), with the responsibility to forward the relevant information to other organisations such as the MHRA, where appropriate. Whilst my focus is on fatal anaphylaxis, inclusion of non-fatal cases would be a matter for the lead role to consider.
4. Gathering data and using this to research and reduce the risk of future deaths requires funding , and this should be reviewed.
” 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 UK Fatal Anaphylaxis Registry; that does not assign responsibility.
PFD Monitor interpretation Lack of national leadership for anaphylaxis work
Wider context from the report “It seems clear to all coroners in these cases, and those involved in this area of medical expertise, that the only way to improve understanding and prevent or reduce future deaths is to gather information nationally and fund appropriate research.
Appropriate organisations already exist, and there is a lot of goodwill towards improving understanding in this area. It does however require national leadership and “joining up” of these organisations.
1. I have tried to make my list of issues clear and succinct. Paragraph 2 below sets out the crux of this ongoing risk.
2. There is significant goodwill and desire to improve amongst numerous organisations involved in anaphylaxis work. What is lacking is national leadership and funding . In my view, consideration should be given to creating a leadership role and responsibility within NHS England to coordinate a national approach.
3. As considered by other coroners before me, it should be mandatory to refer fatal anaphylaxis cases. UKFAR has indicated that they would be prepared to take on the role of receiving these reports (to avoid duplication for reporting clinicians), with the responsibility to forward the relevant information to other organisations such as the MHRA, where appropriate. Whilst my focus is on fatal anaphylaxis, inclusion of non-fatal cases would be a matter for the lead role to consider.
4. Gathering data and using this to research and reduce the risk of future deaths requires funding, and this should be reviewed.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations