Hannah Enola Ayamo Jacobs · Prevention of Future Deaths report

On 17ᵗʰ June 2023 I commenced an investigation into the death of Miss Hannah Enola Ayamo Jacobs aged 13 years. The investigation concluded at the end of the inquest on 16ᵗʰ August 2024. The conclusion of the inquest was a narrative:

On 8ᵗʰ February 2023 Hannah was served a dairy hot chocolate at Costa Coffee Barking despite her mother informing staff of a dairy allergy. Neither she nor her mother were carrying an Adrenaline Auto Injector which had been prescribed. Next, they went to the dentist where Hannah took some sips of her drink and developed symptoms of excessive saliva. During the brief time they were at the dental surgery it was not recognised that this was the beginning of an anaphylactic reaction. Hannah and her mother rushed to the Day Night Pharmacy where Hannah collapsed. LAS attended promptly, began resuscitation, and took her to Newham University Hospital where she was pronounced dead the same day.

• Hannah was 13 with severe allergies to eggs, dairy and wheat. She was going to the dentist before school. Her mother was told she couldn’t take her prescribed Epi-pen into school as she was to keep 2 at home and 2 at school. Hannah’s mother was not carrying an Epi-pen either. They went into Costa Coffee on the way to the dentist where they were incorrectly served dairy hot chocolates. This was due to a failure of communication and a failure to follow the correct allergy process in Costa Coffee. They then went into the dentist and Hannah took a sip of her drink and felt unwell. She went into the dentist’s room spitting out fluid which the dentist believed to be her drink combined with saliva. Hannah refused treatment and left the dentist with her mother to go to a local pharmacy for treatment. Her mother noticed Hannah’s lips were swollen and asked for cetirizine from the pharmacist. Then she asked for an Epi-pen but due to a national shortage there was only one in stock, a 150micrograms rather than the 500 Hannah had been prescribed. This was given but sadly Hannah went in to cardiac arrest and could not be resuscitated.

• The evidence at the inquest referred to allergy action plans discussed in the healthcare settings and given to parents and patients. Hannah displayed what appeared to be excessive salivation at the dentist which her paediatric consultant (who gave evidence) said, with the benefit of hindsight was actually a manifestation of her inability to swallow. This is a sign of anaphylaxis This was not recognised by dental staff as an inability to swallow and thus of anaphylaxis.

• The other symptom Hannah demonstrated was swelling of her lips which is listed on allergy plans as a mild to moderate symptom and thus provided a false sense of reassurance to her mother that cetirizine was what she needed.

• The risk of future deaths in the context of anaphylaxis remains in the absence of further consideration of what constitutes an anaphylactic reaction as opposed to a mild reaction, and the education of parents and patients of the safety of using AAIs (adrenaline auto injectors) IF IN DOUBT.

• I was made aware there had been a shortage of AAI at the time but a vial of adrenaline was available at the chemist. However, it takes time to draw up. I am not sure if (assuming no national shortage) all chemists have AAI in stock for emergencies.