Communication failures led to allergy girl's Costa drink death, coroner says

The mother of a girl who died after having a severe reaction to a Costa hot chocolate has accused the food industry of treating allergen safety training like a "tick-box exercise", after a coroner concluded she died because of a "failure to follow processes."

Hannah Jacobs, 13, of Barking, East London, who was described as "vivacious and affectionate” had a severe dairy allergy and died within hours of sipping the drink bought by her mother on 8 February 2023.

Assistant coroner for London East, Dr Shirley Radcliffe, also found there had been "failure of communication" between the coffee shop staff and Hannah's mother, Abimbola Duyile.

East London Coroner's Court heard that on the day of her death neither Hannah nor her mother were carrying an EpiPen that had been prescribed.

They had visited the Costa Coffee branch in Station Parade, Barking, owned and operated by a franchisee, to buy two soya hot chocolates before Hannah attended the dentist, where she had an appointment before going to school.

After getting to the dentist, Hannah "abruptly got up and went to the toilet and shouted, 'that was not soya milk'", her mother told the inquest.

The court heard standing up while having an allergic reaction could be detrimental and there would have been a need to lie the child down.

Ms Duyile instead rushed Hannah to a nearby chemist as her "lips and mouth were very swollen and she was itchy." Hannah collapsed in the chemist and the pharmacist gave her a paediatric dose of an EpiPen injection in her leg.

The inquest also heard there was a general shortage of EpiPens and that a customer in the chemist, Zeenat Panirwala, who tried to resuscitate Hannah, also had allergies and had an EpiPen.

Pharmacist, Santokh Kahlon, said he would "definitely" have used the extra EpiPen if he had known there was one. He told staff to search for any EpiPens, but none could be found.

Attempts were made to resuscitate Hannah Jacobs, and an ambulance was called, but she was declared dead by 13:00 GMT.

A post-mortem examination found Hannah died after suffering a hypersensitive anaphylactic reaction triggered by an ingredient in her hot chocolate that caused an allergic response.

Barista, Urmi Akter, told the inquest that, when she took the order from Ms Duyile, she had repeated to her the request for a jug be washed out, but had also pointed out that hot chocolate is made from milk.

The inquest also heard that, at the time of Hannah's death, allergen training for new Costa staff involved a series of online modules that could be accessed at home and a quiz that trainees had to pass.

Concluding the inquest, Dr Radcliffe said: "The root cause of this death is a failure to follow the processes in place to discuss allergies combined with a failure of communication between the mother and the barista."

In a statement, Ms Duyile said: "My beautiful Hannah only had 13 years on this earth when she should have had many, many more. Hannah loved life. She was a vivacious, caring, affectionate, outspoken and energetic child with a strong sense of right and wrong.

"Having heard all the evidence over the last week it is clear to me that although the food service industry and medical professionals are required to have allergy training, this training is really not taken seriously enough.

"Better awareness is needed in these industries and across society of the symptoms of anaphylaxis. I have always been extremely diligent in managing Hannah’s allergies and she had never suffered a serious allergic reaction prior to this incident."

A Costa Coffee spokesperson said: "The loss of Hannah is a tragedy, and our heartfelt thoughts remain with her family and friends. Understanding how this awful situation occurred is in the interest of everyone, our franchise partners, our customers, our team members, and the communities of which we are a part. 

"We have listened to everything the coroner has said this week and will carefully consider her comments together with any report she may issue and respond appropriately."

A Department of Health spokesperson said: "Department officials have been in ongoing discussions with the Natasha Allergy Research Foundation about improving support for people with allergies and ministers will carefully consider their views and any recommendations made by the coroner."