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A coroner said he would write to Michael Gove to suggest changing the food labeling regulations to prevent another incident, such as the death of Natasha Ednan-Laperouse.
Natasha, 15, from Fulham, South West London, collapsed on a British Airways flight between London and Nice on July 17, 2016 after eating a baguette of artichokes, olives and tapenade bought at Pret a Manger in Terminal 5 at Heathrow Airport.
The baguette had no advice on the allergens on its packaging. Reduced labeling requirements for locally produced foods meant that it was enough to warn of general allergens, asking customers to consult staff for advice, to post them in stores.
In stating that Natasha died as a result of a "catastrophic anaphylactic reaction from which she could not be saved," Dr. Sean Cummings, Acting Chief Coroner for West London, said Friday that he would be writing to Gove on Secretary of the Environment and Rural Affairs, recommending that the Food Information Regulations be amended.
He also criticized Pret for not taking allergen monitoring seriously.
Dr. Thomas Pearson-Jones was busy with Natasha during the flight after BA staff had made a request for medical help, but the cabin crew did not tell him that he was not there. a defibrillator was on board. Cummings described this as an "omission" but stated that he did not think it had a significant impact on the outcome.
Cummings also made recommendations regarding the length of EpiPens. Dr. Alex Croom, a consultant allergist, told the court on Thursday that the two EpiPen that Natasha was carrying and that had been administered on the plane by his father, Nadim Ednan-Laperouse, may have been ineffective because the 16mm needles were too short and not reaching his muscle.
Cummings said the Resuscitation Council's advice that EpiPens should be 25 mm should be adopted as a standard.
Natasha has suffered from several food allergies, including dairy products, eggs, nuts and seeds. She also had asthma.
Cummings said Natasha had planned a number of trips for the summer and that she was "excited about what she hoped was her best summer to date".
During the investigation, Natasha's father described how she implored him: "Dad, help me, I can not breathe" before crumbling during the flight. Later, when she was at the Nice hospital and told that she would not survive, he said he raised the phone in his ear so that his mother and brother could say goodbye to him. .
Cummings stated that its letter to Gove "would aim to determine whether large food business operators should benefit from the Food Information Regulation".
The coroner said that Pret's allergen-related signs on his refrigerated display cases were "hard to see … I am of the opinion that they were inadequate in terms of visibility".
The survey, which lasted four days, learned this week that Ready to Eat had nine cases of similar allergic reactions in the year before Natasha died. Cummings said its monitoring system for such incidents was "inconsistent and inconsistent".
He said: "Overall, I had the impression that Pret did not take into account the fact that the surveillance of food allergies in a company selling more than 200 million items a year was very serious ".
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