The death of a 13-year-old girl after she took a sip of Costa Coffee hot chocolate was due to a “failure to follow the processes in place to discuss allergies”, a coroner has ruled.
There was also a “failure of communication” between the staff at the Costa in Barking, east London, and the girl’s mother, East London Coroners’ Court heard on Friday.
Hannah Jacobs, who had been severely allergic to dairy, fish, and eggs since she was a toddler, died within hours of taking a sip of the drink that contained cow’s milk on 8 February 2022.
Assistant coroner Dr Shirley Radcliffe said: “The root cause of this death is a failure to follow the processes in place to discuss allergies combined with a failure of communication between the mother and the barista.”
The coroner also noted that on the day of her death, “neither Hannah or her mother were carrying an epi-pen that had been prescribed” for when she was exposed to an allergen.
A post-mortem examination found Hannah died of a hypersensitive anaphylactic reaction triggered by an ingredient in her hot chocolate that caused an allergic response.
In a statement after the hearing, Hannah’s mother said she was “extremely diligent” with her allergies and her daughter took them “very seriously”.
She described her as “vivacious, caring, affectionate and outspoken… with a deep sense of right and wrong”.
“My beautiful Hannah only had 13 years on this Earth when she should have had many, many more,” she said.
She and the family’s legal team from Leigh Day said that allergy training “is not taken seriously enough” and that treating it as a “tick box exercise is not acceptable”.
They thanked a bystander who stepped in to help Hannah, the paramedics who tried to save her, and the coroner.
Went to chemist instead of taking epi-pen
The inquest heard the teenager had an “immediate reaction” to the beverage, despite her mother ordering two hot chocolates with soya milk.
Her mother, Abimbola Duyile, told the hearing she rushed her to a chemist after Hannah drunk the hot chocolate, complained of chest pains and that her lips and mouth were very swollen and itchy.
Urmi Akter, who served Hannah’s mother, told the court she was asked by her: “Can you wash the jug because my daughter has a dairy allergy?”
Ms Duyile was not shown a book containing dietary requirements – as per Costa’s allergen rules – the court heard.
In her statement, Ms Akter said she did not show Ms Duyile the book “as she told me washing the jug was fine”.
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Hannah tasted the drink on the way to the dentist, where she started to feel unwell, prompting nurses to offer Ms Duyile an epi-pen with 300mg of adrenaline, dentist Iqra Farhad told the court.
Ms Farhad said this could have saved Hannah’s life, but Ms Duyile decided to go to the chemist for an antihistamine called Cetirizine instead.
She told the court she only saw Hannah briefly and said “there was no sign of panicking or distress”.
But when they arrived at the chemist there were no epi-pens due to general shortages, pharmacist Santokh Kahlon said in evidence.
He would “definitely” have used the extra EpiPen from the dentist if he had known there was one, he told the court.
Zeenat Panirwala, a customer in the chemist at the time, added Ms Duyile was “struggling” to come to terms with what was happening as she saw Hannah in distress.
She said she heard Ms Duyile blaming Costa for giving her child the drink and was “hysterical saying ‘she’s dead, she’s dead'”.
‘Urgent’ government action needed
Nadim and Tanya Ednan-Laperouse, whose 15-year-old daughter Natasha died after eating a Pret A Manger baguette that had sesame seeds in it, attended Hannah’s inquest and has been supporting her family.
Natasha Ednan-Laperouse who died after eating a Pret A Manger baguette in 2016
They said in a statement afterwards that there is “urgent” need for government action for “schools business and society” to better understand “food allergies can be a serious, unpredictable health condition – not a lifestyle choice”.
“Today, along with Hannah’s grief-stricken mum Abi and on behalf of other parents who have lost children to food allergies, we once again urge the government to appoint an allergy tsar – a national champion for the one in three people who live not just with food allergies, but all types of allergic disease including asthma and eczema,” they said.
“How many more children must die before we start taking food allergy seriously?”
Following Natasha’s death in July 2016, the law was changed to require all food outlets to provide a full ingredients list and allergy labelling on food pre-packaged for direct sale.