Families of anaphylaxis victims demand changes to inquest system

Grieving families who have lost loved ones as a result of severe allergic reactions are calling for urgent changes to the inquest system, warning that the current set-up has failed to learn from past tragedies.

The Natasha Allergy Research Foundation said investigations into deaths caused by anaphylaxis should become mandatory.

The charity is also calling for near-fatal reactions to be reported nationally, with an allergy tsar appointed to help drive change.

The recommendations are based on a new study that found there is no single data source to determine the full extent of anaphylaxis deaths in England and Wales, preventing real-time analysis that could save lives.

Anaphylaxis is a severe allergic reaction triggered by things like food, drugs and venom.

However, the number of deaths it causes is unclear, with estimates ranging from 20 to more than 8,600 a year, according to the new report by Dr Georgia Richards, an epidemiologist at King’s College London and founder of the Preventable Deaths Tracker.

Coroners investigate sudden, suspicious or unexplained deaths, and may issue prevention of future deaths (PFDs) reports if they believe action can be taken to prevent deaths.

However, the study found not all anaphylaxis deaths are investigated – despite often being sudden and unexplained – with the equivalent of just two PFDs a year issued involving deaths from severe allergic reactions.

The analysis included 6,000 PFDs and found just 32 that involved anaphyalxis between 2013 and 2025, the equivalent of two deaths a year, which the report describes as the “tip of the iceberg”.

According to researchers, every death involving anaphyalxis during this period was preventable.

Some 189 concerns were raised by coroners in these reports, mostly regarding lack of education and training when it comes to allergies and national oversight.

PFDs are issued to organisations in a position to take action, and require them to respond withing 56 days about what steps will be taken.

However, the study found just 45% of the 68 organisations that were sent PFDs after anaphyalxis deaths responded.

The analysis also suggests children between the ages of 10 and 17 were at the greatest risk of anaphylaxis.

It comes as hospital admissions for severe allergic reactions to food have tripled in the last two decades, the report warned.

Dr Richards said: “Anaphylaxis is the worst illustration we have seen to date, where coroners are not only raising the same concerns in PFDs time and time again, but are repeatedly referring to other PFDs written by their colleagues, still – nothing is being done.”

The report is calling for all anaphylaxis deaths to be examined by a coroner on a mandatory basis, with a new national reporting system brought in for all anaphylactic events, including near-fatal reactions.

It also recommends the implementation of a national database for all deaths investigated by coroners in England and Wales, and calls for an allergy tsar to be appointed to help drive change.

Dr Richards added: “Harnessing information from coroners could save lives from anaphylaxis. Urgent action is needed to prevent future deaths, including the appointment of a national allergy lead – an allergy tsar – to drive through change.”

The Natasha Allergy Research Foundation was founded by Nadim and Tanya Ednan-Laperouse after their 15-year-old daughter Natasha died after eating a baguette which did not have sesame listed as an ingredient.

The couple said: “Natasha’s death in 2016 from anaphylaxis was entirely preventable. It should never have happened. To lose a child to anaphylaxis is devastating.

“To fail to learn from the mistakes made, to help keep others safe and prevent future deaths, is unthinkable.

“We hope this study will help to shine a light on the need for action so that no more parents have to go through the terrible loss that we will always endure.”

The launch of the report was attended by other grieving families, including Abimbola Duyile, whose 13-year-old daughter Hannah Jacobs died from a reaction to milk in a Costa drink in 2023, Emma Turay, whose daughter Shante Turay-Thomas, 18, died from after eating hazelnuts in 2018, and Mike and Aicha King, whose daughter Lily, 18, died after a reaction to food in Morocco in 2024.

Ms Turay said: “After reading this report, I feel lucky that an inquest was carried out into Shante’s death and a Prevention of Future Deaths report issued.

“Yet five years on from the inquest, the coroner’s concerns about the lack of a national allergy lead, an allergy tsar, to act as a champion for people living with allergies and drive forward change, have still not been acted upon.”

Michelle Victor, partner and head of the food safety team at law firm Leigh Day which co-sponsored the event with Natasha’s Foundation, said: “There has been a systematic failure to implement changes following inquests charged with investigating fatal food-induced anaphylaxis.

“The coronial system designed to prevent future deaths in such circumstances is failing families. The litany of failures identified at various inquests have not led to meaningful change.

“Losing a loved one in such circumstances is devastating, not seeing changes to prevent another death is indefensible. The lack of a coordinated national system to collect data and act on learnings from fatal anaphylaxis cases needs to change and now.”