A national register for allergen-related deaths could help avoid future tragedies, the coroner who led the inquest into the death of 14-year-old Ruben Bousquet has said.
Senior coroner Andrew Harris published a report to prevent future deaths following the inquest, highlighting the lack of national reporting and registering of allergic reactions as a matter of concern.
Ruben died in 2019 of acute anaphylaxis to cow’s milk allergen from cross-contamination of popcorn, which he had eaten at a cinema in Greenwich, southeast London.
Harris said in his report: “In my opinion action should be taken to consider establishing a national reporting system which includes timely reporting to local authority and the Food Standards Agency (FSA) and maintenance of a register of fatalities and their investigations.”
This is the third time a coroner has made reference to a national register in a report to prevent future deaths. The coroner who led the inquest into the death of Owen Carey, 18, who died in 2017 after eating a burger marinated in buttermilk despite making restaurant staff aware he was allergic to it, expressed concern that there was no national register from which specialists could learn. The coroner in the inquest into the death of Dylan Hill, also 18, from eating a curry containing peanuts in a Barnsley restaurant in 2015, also suggested that information about anaphylaxis incidents should be brought together.
Ian Andrews, a head of service at the London borough which, unusually, investigated both Ruben’s and Owen’s cases, said: “A national register would enable anybody with access to the details over time to identify what product/products or allergens are commonly causing these incidents. You could then go on to identify best practice and guidance and it feeds into the whole food safety management and risk management framework, learning from others’ experience.
"It's important that we see quick reporting of allergy incidents to local authorities as this brings about effective investigations.”
Andrews, who also chairs the National Food Hygiene Focus Group, added: “This is an issue we have been pushing at for a while, particularly in respect to how allergens are being included within the food hygiene rating scheme.”
He also pointed out that allergen-related deaths are not currently included within the Work-related Deaths Protocol (WRDP), a document that guides joint working signed by nine organisations including HSE, British Transport Police and the Local Government Association. He and colleagues have been lobbying the WRDP committee to consider including allergens with some success, although it hasn’t yet happened.
CIEH has also been looking for ways to make allergen-related incidents, including deaths and near-misses, reportable. In its response to the government’s allergen food labelling consultation in 2019 it said: “A notification system could be put in place with the facility for notifications to be made centrally, for example via the FSA website. This would be accessible to NHS staff, consumers and local authorities. Notifications could be automatically re-directed to the relevant local authority for investigation and/or action. Near-misses could also be made reportable under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR), along with clear guidance and quick communication to local authorities for investigation.”