Prevention of Future of Death report following Celia Marsh inquest 

Prevention of Future of Death report following Celia Marsh inquest 

  • 07 December 2022
  • News

Following the conclusion of the inquest into the death of Celia Marsh, the coroner has issued a Prevention of Future Deaths Report. 

Prevention of future deaths reports are written when the coroner has heard evidence that further deaths might happen if action is not taken to prevent this. The report is sent to those with the power to make the changes needed. They must reply within 56 days saying how they plan to respond. 

Celia Marsh died on 27th December 2017 at Royal United Hospital, Bath. She had a known allergy to milk. On that day whilst in Bath City Centre she ate a super veg rainbow flatbread which she believed was safe to eat; she suffered anaphylaxis caused by milk protein which was in an ingredient within the wrap; this caused her to collapse and despite the efforts of the medical teams involved, she died. 

Maria Voisin, Senior Coroner for Avon, concluded that: 

“Celia was allergic to milk, she suffered anaphylaxis caused by the consumption of a wrap; the wrap was contaminated with milk protein. Celia was not aware that the wrap contained milk protein. The wrap contained a product which was marked as “dairy free coconut yogurt alternative”, but despite this it contained milk protein, which was the cause of Celia’s anaphylaxis. A product which is marked “dairy-free” should be, free from dairy. The contamination arose because an ingredient in the yogurt called HG1 had become cross-contaminated with milk protein during its manufacture. The manufacturer of the dairy free yogurt had in its possession documents which flagged this risk but this risk was not passed on to its customers.” 

The inquest determined that there is a risk of future deaths if action is not taken, and the senior coroner has made several recommendations. The report has now been sent to the chief coroner and to the relevant organisations with responsibility in the following areas: 


Concerns have been raised about how evidence is obtained and managed in the immediate investigation that follows a suspected death from anaphylaxis.  

Current guidance is 10 years old and should be revised to specifically include that:- 

  • bloods taken in a suspected case of anaphylaxis are retained for testing, not destroyed 
  • an early blood sample is taken after death and stored for later analysis  
  • the post mortem is prioritised and appropriate samples taken and preserved (governed by a standard protocol) 
  • the possibility that the death is due to anaphylaxis is raised with the senior coroner at the earliest opportunity.  

Anaphylaxis Fatality Register 

There is a call to establish a robust system of capturing and recording cases of anaphylaxis, to provide an early warning of the risk posed to people with allergies by products with undeclared allergens. Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases.  

Food labelling 

The report raises concerns around food labelling, in particular the public’s understanding of phrases implying the absence of a particular allergen, which can be misleading. Examples include ‘free from’ and ‘vegan’. The report called for a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such claim.  

The report also recommended the creation of a hotline to the Food Standards Agency (FSA) to provide guidance in fatal cases due to suspected anaphylaxis and for national best practice and technical advice to assist those investigating such cases.  

Simon Williams, chief executive of Anaphylaxis UK, said: 

“Anaphylaxis UK would once again like to extend our deepest sympathies to the family of Celia Marsh. We support the need for a reporting system to record information about anaphylaxis cases to help understand the causes behind anaphylaxis-related deaths and how to prevent future early deaths. We recently supported the call for increased funding for the UK Fatal Anaphylaxis Registry (UKFAR) to help meet this aim.    

“We also support the need for tighter regulation and testing of products to verify allergen-free claims and greater awareness around the risk of cross-contamination throughout the whole food manufacturing supply chain.”