Investigation and inquest
On 29ᵗʰ July 2020 I commenced an investigation into the death of Samantha Singh, 26 years old. The investigation concluded at the end of the inquest on 22ⁿᵈ June 2021. The conclusion of the inquest was cause of death:
1a Anaphylactic shock
1b Allergy to nuts
A short form conclusion of accidental death was arrived at.
Circumstances of the death
Miss Samantha Singh attended her general practitioner’s surgery in November 2019 to raise a concern regarding her suspicion that she suffered from a nut allergy. Following a RAST test Miss Singh was assessed to suffer from a mixed nut allergy, she was prescribed an EpiPen.
On 25 July 2020 Miss Singh became unwell at home and suffered a cardiac arrest attributable to anaphylactic shock. Despite best efforts of her family and emergency services she could not be resuscitated.
Coroner’s concerns
(1) Results of Miss Singh’s RAST test were wrongly categorised by the surgery as normal. As such, no further action was indicated by the surgery. It was only Miss Singh’s perseverance that led to a follow-up appointment being arranged to discuss the results with her GP where the mistake was discovered
(2) At a GP appointment on 27 November 2019, Miss Singh was prescribed a single EpiPen. NICE guidance at the time indicated that no fewer than two epi-pens should be prescribed to a patient.
(3) Following the appointment on 27 November 2019 Miss Singh was not referred to allergy clinic or offered a follow-up appointment to address issues arising from her allergy diagnosis.