After a severe allergic reaction to a hot chocolate, a “national shortage” of EpiPens meant that a pharmacist could not prevent the death of 13-year-old Hannah Eniola Angela Ayomipo Jacobs, a coroner has found.
In a report published last week (August 30), coroner Dr Shirley Radcliffe said that Jacobs was “incorrectly” served a “dairy hot chocolate at Costa Coffee Barking despite her mother informing staff of a dairy allergy” on her way to a dentist appointment on February 8 2023.
The report said that when the pair arrived at the dentist, Jacobs “took a sip of her drink and felt unwell”.
Read more: Coroner: Patient dies after pharmacy supplied 'additional methadone’
Jacobs had “severe allergies to eggs, dairy and wheat” but “neither she nor her mother were carrying an adrenaline auto injector that had been prescribed”, it added.
She “refused treatment and left the dentist with her mother to go to a local pharmacy for treatment”, the report said.
Jacobs and her mother “rushed to the Day Night Pharmacy where [she] collapsed” before she “sadly…went into cardiac arrest and could not be resuscitated,” it added.
“Insufficient dosage”
In a second report also published last week, the coroner said that when Jacobs entered the pharmacy “her mother asked for cetirizine that had previously helped” but “it was given to no effect”.
“An EpiPen was requested but due to a national shortage of adrenaline auto injectors, the pharmacist had only one paediatric injector that was of an insufficient dosage,” she added.
The “only one in stock” was “150 micrograms rather than the 500 [Jacobs] had been prescribed”, Radcliffe said.
Read more: Coroner: Man dies by suicide after GP deregistration despite pharmacy plea
“I was made aware there had been a shortage of adrenaline auto injectors at the time, but a vial of adrenaline was available at the chemist,” she added.
“However, it takes time to draw up,” she said.
“I am not sure whether – assuming no national shortage – all chemists have adrenaline auto injectors in stock for emergencies,” she added.
“Action should be taken”
Radcliffe found that there is “a risk that future deaths could occur unless action is taken”.
She sent her findings to health secretary Wes Streeting, NHS England’s (NHSE) national medical director and chief executive of the General Pharmaceutical Council (GPhC) Duncan Rudkin, among various others.
She stressed that “action should be taken” by the organisations and instructed them to reply “within 56 days of the date of this report, namely by October 15”.
Read more: Coroner: Patient died from overdose after GP pharmacist ignored warning
The Department of Health and Social Care (DH) told C+D today that its “deepest sympathies are with the family and friends of Hannah Jacobs and all those impacted by this case”.
"We have been in ongoing discussions with the Natasha Allergy Research Foundation about improving support for people with allergies,” it added.
“Ministers will carefully consider their views and any recommendations made by the coroner following the tragic death of Hannah Jacobs,” it said.
Read more: Opinion: The DH needs to act on allergies after latest death
A GPhC spokesperson told C+D that it too is "currently carefully reviewing this prevention of future deaths report".
And NHSE also said that it "extends its deepest sympathies to the family and friends of Hannah Jacobs", is "carefully considering" the report and "will respond in due course”.
C+D also approached Costa Coffee and the pharmacy for comment.
