Pret a Manger has the power to take action to prevent future deaths, a coroner at the inquest into the death of teenager Natasha Ednan-Laperouse has concluded.
Ednan-Laperouse, then 15, died in July 2016 following a catastrophic allergic reaction after unknowingly eating sesame seeds contained in an artichoke, olive and tapenade baguette, which she had bought from a branch of Pret at Heathrow. The teenager was with her father when she collapsed on board a flight to Nice.
Natasha’s father, Nadim Ednan-Laperouse, said she died because of “inadequate food labelling laws” and joined the rest of her family, from Fulham, south-west London, in calling for a change in the law to save lives. The baguette did not have any allergen advice on its wrapper. There was no requirement for it to do so because of reduced labelling requirements for food produced on site.
Ednan-Laperouse described the inquest into his daughter’s death as a “watershed moment” that should prompt a change in the law.
In a report published on Tuesday, coroner Dr Sean Cummings outlined “matters of concern” identified in Natasha’s inquest and wrote: “In my opinion there is a risk that future deaths could occur unless action is taken.”
He said allergens were not “labelled adequately or clearly” on Pret packaging when products were prepared in their kitchens for direct sale under regulation 5 of the Food Information Regulations.
The regulations state that for items made in store it is sufficient for general allergen warnings to be posted around the shop, rather than on the packaging, and for specific advice to be given orally by staff. The rules make no distinction between small sandwich shops and large chains such as Pret.
“I was left with the impression that the ‘local kitchens’ were in fact a device to evade the spirit of the regulation,” Cummings wrote in his report.
He also said there had been “no coherent or co-ordinated system for monitoring customer allergic reactions” despite more than 200 million items being sold a year, adding that the current system “remains highly inadequate”.
“In my view, sales of 200 million items, some with expressly commissioned but hidden allergens, require a robust safety auditing system. The previous system was unsafe and the system proposed equally so in my view,” he said.
The coroner also highlighted concerns over the “inadequate” length of EpiPens and of adrenaline doses, the combination of which “raises serious safety concerns”.
Cummings concluded that Pret’s chief executive, Clive Schlee, the environment secretary, Michael Gove, the Medical and Healthcare products Regulatory Agency and the chief executive of Pfizer have the power to take action.
The named parties must respond to the report by 3 December 2018 with details of any action taken.
A spokesperson for Pret said: “Following the coroner’s conclusion at the inquest, we announced last week that we are moving to full labelling of all products produced in our kitchens as quickly as possible, with immediate measures in the meantime,” it said.
“We have also committed to improving our monitoring and complaints handling procedures to ensure allergy-related incidents are immediately escalated and reported on within 24 hours.
“We will be working with others, including the government, regulatory authorities, charity groups and industry peers, to secure legislative changes to better protect people with allergies and deliver what the Ednan-Laperouse family have called for.”
The coroner’s conclusion followed calls for answers from the family of a second person thought to have suffered a fatal allergic reaction to a Pret a Manger sandwich. Celia Marsh, 42, died on 27 December last year after eating a super-veg rainbow flatbread containing a yoghurt that was supposed to be dairy-free but was found to be contaminated with dairy.
In a statement released on Monday, her family, from Melksham in Wiltshire, said: “We have kept a dignified silence since the death of Celia in December last year as the family has come to terms with her sudden and unexpected death. We are also awaiting the outcome of the investigations into how she died.”
Avon coroner’s office said Marsh died at the Royal United hospital in Bath, and that inquiries were continuing.