A 13-year-old girl with a severe dairy allergy died after drinking a Costa Coffee hot chocolate after a “failure to follow the processes in place to discuss allergies”, an inquest has concluded.
Hannah Jacobs, from Barking, east London, who had been severely allergic to dairy, fish and eggs since she was a toddler, died within hours of taking a sip of the drink on 8 February 2023, east London coroner’s court was told.
The assistant coroner Dr Shirley Radcliffe said there had been “failure of communication” between Hannah’s mother and the coffee shop staff, which led to hot chocolate that was made with cows’ milk instead of soya milk being served.
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.”
The coroner also noted that on the day of her death, “neither Hannah nor her mother were carrying an EpiPen that had been prescribed”.
A postmortem found Hannah had died after suffering a hypersensitive anaphylactic reaction triggered by an ingredient in her hot chocolate.
In a statement read by her lawyer outside the inquest, Hannah’s mother, Abimbola Duyile, said treating allergy training as a “tick-box exercise” was not acceptable.
She said: “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. And better awareness is needed in these industries and across society of the symptoms of anaphylaxis.
“Hannah was just entering adolescence and learning to be independent, taking ownership of her allergies when she was tragically taken from us.”
Duyile said she had always been “extremely diligent” in managing her daughter’s allergies, and Hannah had never suffered a serious allergic reaction before this incident.
Describing Hannah as “vivacious, caring, affectionate, outspoken and energetic”, she said her daughter “had everything to live for and was so full of life and promise”.
Duyile held a framed photograph of Hannah and cried as the statement was read out.
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.”
After buying the drink in a Costa Coffee branch in Station Parade, Barking, Hannah and her mother attended a dentist appointment at East Street dental practice in Barking. Hannah took a sip of her drink while in the waiting room and suffered an “immediate reaction”, the inquest heard.
Hannah and her mother left the dental practice and went to the nearby Day Night pharmacy and a junior EpiPen was administered. She was taken by ambulance to Newham hospital, where she was declared dead at 1pm.
The barista Urmi Akter previously told the inquest she took the order from Duyile and said she had repeated the mother’s request that a jug be washed out and pointed out that hot chocolate was made from milk.
Duyile was not shown a book containing dietary requirements as according to Costa’s allergen rules, the hearing was told.
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, the inquest had heard.
Duyile’s legal team at Leigh Day said she believed there were still many lessons to be learned, including “robust training” in the food service industry and “extra safeguards by implementing a process for the order details to be printed and stuck to coffee cups”.
They welcomed the coroner’s decision to write to government departments to consider the practicalities of children with allergies carrying adrenaline when travelling to and from school, and called on the Department of Health to provide further education to the general public, medical professional and businesses on managing allergic reactions which require adrenaline.
They said Hannah’s mother also supported the call by the Natasha Allergy Research Foundation – set up by the parents of Natasha Ednan-Laperouse, 15, who died after a severe allergic reaction to a Pret a Manger baguette – for a dedicated person in government to ensure people with allergies receive proper support and joined up healthcare to prevent avoidable deaths and ill health.