The Coroner has ended the inquest into the death of Shante Turay-Thomas and has delivered her narrative determination and highlighted the contents of the Prevention of Future Deaths report that she will deliver.
The Anaphylaxis Campaign would like to extend our deepest condolences to the family of Shante, who died aged 18 at her home in North London in 2018 after eating food thought to have contained nuts. Shante was known to have unstable asthma and a severe nut allergy.
The Anaphylaxis Campaign Chief Executive Officer, Lynne Regent personally attended the Inquest to offer support to Shante’s family and to understand the lessons that can be learnt from her tragic death. Significant issues were raised in a number of areas and involved many parties. These included the Ambulance Services, NHS Digital, the local Clinical Commissioning Group (CCG), GP Services and the manufacturer of Emerade, Bausch and Lomb. We await the publication of the Coroner’s Prevention of Future Deaths Report but in the meantime the Anaphylaxis Campaign will look carefully at the lessons to be taken forward.
CEO Lynne Regent, said:
“It is vital that lessons are learned from Shante’s tragic death and that the Coroner’s findings are promptly acted upon by the organisations concerned.”
The issues raised during this inquest include;
Emergency response to Anaphylaxis
Adrenaline should be administered as early as possible to work effectively. We advocate that if you are unsure whether an allergic reaction is severe enough to require adrenaline, then it should be administered.
The inquest has highlighted that in a suspected anaphylactic reaction, any emergency calls to 111 and 999 should always be triaged as Category 1, meaning an ambulance is estimated to reach the patient in an average time of seven minutes.
The British Society for Allergy & Clinical Immunology highlight the following symptoms to help recognise a potentially life-threatening allergic reaction
- Airway: persistent cough, hoarse voice, difficulty swallowing, swollen tongue
- Breathing: difficult or noisy breathing, wheeze or persistent cough
- Consciousness: persistent dizziness/pale or floppy, suddenly sleepy, collapse, unconscious.
Education and Training
Findings from the inquest indicate that more awareness and training is needed for those involved in dealing with an anaphylactic reaction. It’s vital that GPs ensure the correct training, doses and advice are given to all those that are prescribed adrenaline.
The inquest heard how Shante had not been given sufficient training on how to use her Adrenaline Auto-Injector (AAI) which had been changed from EpiPen to Emerade and that the dose was incorrect. There was also incorrect advice given from the local CCG to GPs.
If a patient is switched from one device to another, this could cause confusion and so careful retraining is necessary. It is vital that anyone prescribed an AAI is shown how to use their specific device.
Training should also be given to anyone who might be required to give the patient adrenaline in an emergency, such as a carer or school and nursery staff.
Carrying Two Adrenaline Auto Injectors
The inquest heard how Shante carried one AAI and kept another AAI at her school. The Anaphylaxis Campaign would like to reiterate advice that medical professionals should prescribe two devices to patients in line with the UK’s Medicines and Healthcare Products Regulatory Agency (MHRA) recommendations and that patients should carry two AAI’s with them at all times.
There have been reports of Emerade pens failing to activate, however, it could not be determined whether the device had failed to activate in this case.
Emerade devices are not currently being supplied whilst the reports are being investigated. Read the latest statement on this here: https://www.anaphylaxis.org.uk/2019/11/28/mhra-issues-emerade-alert-update/
The Anaphylaxis Campaign would like to reinforce the following advice;
- Always carry two adrenaline auto-injectors with you at all times.
- Ensure you have registered the expiry date of your devices on the relevant manufacturers websites to give you ample warning when a new prescription is required.
- Ensure you gain a replacement device prior to disposing of any out of date devices.
- Always make sure you have a trainer device which can be ordered from the manufacturer’s websites for free:
Make sure that your family and friends are familiar with the device you have and how to use it. If you experience symptoms of anaphylaxis, administer an adrenaline pen without delay, even if you are not sure whether it is anaphylaxis. Early administration is vital.
In an emergency call 999, ask for an ambulance and say anaphylaxis (pronounced as ‘anna-fill-axis’).
The role of the coroner and purpose of an inquest
We wish to make it clear that the Anaphylaxis Campaign are not legal experts. We understand that the extensive media coverage of the inquest has raised several questions from our supporters about the role of the coroner and purpose of an inquest.
A coroner is appointed by a local authority and investigates deaths reported to them to find out who has died and how, when, and where they died. An inquest is a public court hearing held by the coroner to discover the facts about the circumstances of someone’s death. There are a very limited number of specific legal terms used to record cause of death. The coroner decides who should be called to give evidence as a witness. If a witness lives in England or Wales, they must attend if they are asked; if they live abroad, they do not have to attend.
An inquest is different from other types of court hearing because there is no prosecution or defence. The purpose of an inquest is to establish the relevant facts and cannot blame someone for someone’s death. The coroner or jury cannot find a person or organisation criminally responsible for someone’s death. For legal reasons, therefore, we cannot comment on certain aspects of any inquest. The Ministry of Justice has produced a booklet called a ‘Guide to Coroner Services’ and if you are interested in the coronial process, you may find it helpful to read: https://www.gov.uk/government/publications/guide-to-coroner-services-and-coroner-investigations-a-short-guide.
If you have any further questions, please contact the Helpline on 01252 542029 or email [email protected]