Background This is not new territory. Several coroners have raised concerns similar to mine. Those listed below are simply the cases where coroners have sent Regulation 28 reports. There may well be others. Previous cases include :
1. In the case of Shante Turay-Thomas (who I believe was 18 at the time of her death), the Senior Coroner for Inner North London stated: “The issues within this Prevention of Future Deaths report are predominantly national issues, but I heard at inquest that there is no person with named accountability for allergy services and allergy provision at NHS England, or the Department of Health as a whole.”

Berkshire Coroner’s Office

2. In the case of Robin Bousquet (who I believe was 14 at the time of death), the Coroner for Inner South London stated in a Regulation 28 Report to Prevent Future Deaths: “In my opinion action should be taken to consider establishing a national reporting system which includes timely reporting to local authority and FSA and maintenance of a register of fatalities and their investigations, and consideration be given to investigating the feasibility of wider access to AAIs. I believe that the organizations would wish to learn of the circumstances of this death and are in a position to facilitate a collaborative process to mitigate or prevent future deaths.”
3. In the case of Ms Celia Marsh (who I believe was 42 at the time of her death), the coroner touched on many of the issues I will refer to in this report. She stated the following: “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this, changes are required. In relation to the Food Standards Agency, the UK Health Security Agency, and the Department of Health and Social Care:  To establish a robust system of capturing and recording cases of anaphylaxes, and specifically, fatal and near-fatal anaphylaxis…  Such a system could involve, mandatory reporting of anaphylaxis presenting to hospital analogous to the current system for notifiable diseases… by registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the State of Victoria in Australia, and allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate public health risk.” Alexandra’s case

Berkshire Coroner’s Office

It seems clear to all coroners in these cases, and those involved in this area of medical expertise, that the only way to improve understanding and prevent or reduce future deaths is to gather information nationally and fund appropriate research. Appropriate organisations already exist, and there is a lot of goodwill towards improving understanding in this area. It does however require national leadership and “joining up” of these organisations. 1. I have tried to make my list of issues clear and succinct. Paragraph 2 below sets out the crux of this ongoing risk.
2. There is significant goodwill and desire to improve amongst numerous organisations involved in anaphylaxis work. What is lacking is national leadership and funding. In my view, consideration should be given to creating a leadership role and responsibility within NHS England to coordinate a national approach.
3. As considered by other coroners before me, it should be mandatory to refer fatal anaphylaxis cases. UKFAR has indicated that they would be prepared to take on the role of receiving these reports (to avoid duplication for reporting clinicians), with the responsibility to forward the relevant information to other organisations such as the MHRA, where appropriate. Whilst my focus is on fatal anaphylaxis, inclusion of non-fatal cases would be a matter for the lead role to consider.
4. Gathering data and using this to research and reduce the risk of future deaths requires funding, and this should be reviewed.
5. Information sharing amongst the organisations referred to in this report should be straightforward. Confidentiality constraints are important, but not the same in the case of a deceased person as they are for a living person. I believe that a confidential advisory group has already started to consider this matter.
6. Consideration of including contact details for the UKFAR in algorithms used by doctors attempting to resuscitate patients – so that there is a clear requirement for referral to UKFAR in the event of an unsuccessful resuscitation. This is currently being considered by the Resuscitation Council UK. For my part, I have taken the following steps to increase awareness in the work that

Berkshire Coroner’s Office

I do :
1. I have taken responsibility for making my fellow coroners aware of the existence of UKFAR and circulated guidance to them to use in anaphylaxis cases.
2. The Royal College of Pathologists is reviewing their guidance, and I intend to circulate interim guidance which coroners can send to their pathologists, pending this more official guidance.
3. I will also send all coroners nationally a guidance note to use for their local police forces in gathering appropriate evidence at the scene of a likely anaphylaxis case.