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Human error a factor in teenager's allergy death.


A teenager with a severe nut allergy died partly because of human error, a coroner has ruled.

Ms Shante Turay-Thomas, 18, from London had a severe reaction to eating a hazelnut.

The inquest into her death heard a series of failures meant that an ambulance took more than 40 minutes to arrive at her home in Wood Green, north London.

The inquest heard call staff for the NHS's 111 non-emergency number failed to appreciate the teenager's worsening condition was typical of a severe allergic reaction to nuts.

A telephone recording of the 111 call, made by her mother, on Friday 14 September 2018, revealed how the teenager could be heard in the background struggling to breathe.

She said: "My chest hurts, my throat is closing and I feel like I'm going to pass out" before asking her mother to check how long the ambulance would be. She then added: "I'm going to die."

The inquest heard Ms Turay-Thomas had tried to use her auto-injector adrenaline pen, although she had injected only a 300-microgram dose, rather than the 1,000 micrograms needed to stabilise her condition.

It also became clear that Ms Turay-Thomas was unaware of the need to use two shots for the most serious allergic reactions and had not received medical training after changing her medication delivery system from the EpiPen to a new Emerade device.

The inquest at St Pancras Coroner's Court was told an ambulance that had been dispatched to her house had been rerouted because the call was incorrectly categorised as requiring only a category two response, rather than the more serious category one.

The ambulance eventually arrived more than 40 minutes after she first contacted the 111 service. Ms Turay-Thomas died later in hospital, with a post-mortem examination identifying acute anaphylaxis as the cause of death.

Returning a narrative verdict, coroner Mary Hassell, said Ms Turay-Thomas would have survived had she been given "appropriately robust training" about treating her condition and had administered the correct dose, if the 111 call-handler had responded correctly to her condition, and if NHS Digital had categorised anaphylaxis as requiring a category one response.

She added that she intends to make a prevention of future deaths report highlighting areas of concern.

The teenager's mother said: "What has kept me going throughout this process is knowing that she would want me to get answers and make sure the same thing doesn't happen to anyone else.

"The coroner highlighted the fact that no one person in NHS England or the Department of Health is responsible for allergies, and it is quite clear we need an allergy tsar to co-ordinate and implement steps to prevent others from suffering avoidable deaths like Shante's."

Tanya and Nadim Ednan-Laperouse, who set up the Natasha Allergy Research Foundation following their own daughter's death from anaphylaxis, said the inquest "exposed huge systemic failures at all levels of our healthcare system.”