James Stuart Atkinson · Prevention of Future Deaths report

On 16 July 2020 I commenced an investigation into the death of James ATKINSON. The investigation concluded on 15 January 2024 at the end of the inquest. The conclusion of the inquest was

(2) Anaphylaxis following peanut ingestion

(4) James Stuart Atkinson died on 10th July 2020 after eating a Chicken Tikka Masala pizza purchased from Dadyal Takeaway Restaurant in Newcastle upon Tyne via Deliveroo application. The pizza contained peanuts to which he was allergic.

The Dadyal menu did not contain specific information in respect of peanuts or other allergens.

James did not contact the takeaway to advise them of his allergy.

He ate the pizza, following which he suffered an anaphylactic reaction. No Epi-pen was located and delayed his access to adrenaline until Paramedics attended.

James was 23 years old with a history of Asthma. In 2010 he was confirmed to have an allergy to nuts and in particular peanuts.

He was prescribed an Epi-pen and antihistamines to manage his allergy. His Epi-pen was renewed only on his request, James last requested his Epi-pen in 2015. He attended 3 asthma reviews prior to his death. His allergy was not addressed during the reviews. There was no regular allergy review procedure provided locally or nationally.

On 10 July 2020 he ordered food for himself and flatmates from Dadyal Takeaway Restaurant. Their menu contained limited information as to the ingredients used in the dishes produced and no allergen information or allergen matrix. James ordered a Chicken Tikka Masala pizza. The presence of peanuts in both the dishes produced and in use in the kitchen was not referred to in the menu. James knew about his nut/peanut allergy. He did not contact Dadyal to advise of his allergy and was unaware that the Chicken Tikka Masala pizza ordered contained mixed nut powder comprising of up to 99 per cent peanuts. He suffered an allergic reaction shortly after consuming the pizza. He called an ambulance which arrived within four minutes of his call. His Epi-pen could not be located; missing an opportunity for an adrenaline injection prior to Paramedic arrival. Despite Paramedic and hospital care and treatment James died due to anaphylaxis resulting from peanut ingestion.

The evidence in this case unequivocally established that James was not under regular review for his allergy, risk of anaphylaxis and the benefits of automatic adrenaline injectors.

The report of ████████ (attached) identifies the need for wider consideration of a systematic approach to improving anaphylaxis awareness and management.

The risk of future deaths in the context of allergy/anaphylaxis remains in the absence of an appropriate structure to educate, review and manage those who are diagnosed allergies.