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Investigation and inquest
I opened an inquest into the death of Master Ruben Bousquet (case ref ████████) who died aged 14 on 18.04.19 in Evelina Children’s Hospital. The inquest was concluded on 5th August 2020. The conclusion as to how he came by his death was given as: Acute anaphylaxis to cows milk allergen from cross contamination of popcorn.
Circumstances of the death
Master Ruben Bousquet was exquisitely sensitive to certain food allergens, principally milk protein food, which had led to 3 hospital admissions. On 17.04.19, he ate some sweet unpackaged popcorn, purchased from a cinema in Greenwich, and began to feel unwell. He was driven home to access his emergency treatment for anaphylaxis, and became distressed about 15 minutes after consumption, about 3 minutes from home. He collapsed and was given Adrenaline injections twice and effective CPR. Ambulance crews arrived after about 5 minutes, found severe bronchospasm, which delayed endotracheal intubation, released a tension pneumothorax and gave advanced cardiopulmonary resuscitation. He remained unconscious and was taken to Evelina Hospital where he was found to have developed irretrievable brain damage inconsistent with life and died at 19.25 on 18.04.19. The popcorn was manufactured and supplied free from milk protein, but had become cross contaminated at some stage in the food chain, which could not be determined, partly because appropriate food testing was not conducted in a timely manner, and partly because the level of allergen likely to trigger his response was thought to be close to the limit of detection.
Coroner’s concerns
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.
2. Availability of emergency Adrenaline Auto-injector devices (AAIs) in the Retail food sector
Ruben’s parents have asked that the feasibility of food businesses being issued with AAIs. An Environmental Health officer has advised that this would need a change in the law and that such a change would potentially create new risks to lives, as well as the potential to save others. The court has heard no substantive evidence on whether the matter has been officially investigated and it is unclear whether its benefits outweigh its disadvantages, but it clearly has the potential to save lives.
Information checked against the published report and official responses