Coroner rules teenager with severe dairy allergy died as a result of Costa Coffee failures
Hannah Jacobs passed away last year hours after drinking a hot chocolate at a Costa Coffee in Barking
Last updated 16th Aug 2024
A 13-year-old girl with a severe dairy allergy died after drinking a Costa Coffee hot chocolate following a "failure to follow the processes in place to discuss allergies", an inquest has concluded.
Assistant coroner Dr Shirley Radcliffe also said there had been "failure of communication" between the coffee shop staff and Hannah Jacobs' mother.
The teenager died within hours of taking the drink on February 8 2023, East London Coroner's Court was told.
Dr 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 or her mother were carrying an epi-pen that had been prescribed".
A post-mortem examination found Hannah died after suffering from a hypersensitive anaphylactic reaction triggered by an ingredient in her hot chocolate that caused an allergic response.
Costa Coffee says it's changed its training in response to Hannah's death.
Costa Coffee employees give evidence to inquest
Faton Abrashi, a regional operations manager for Costa Coffee stores in London whose responsibilities include allergy procedures for staff, told the court on Thursday that Costa baristas were only permitted to serve customers who had stated they had an allergy when ordering if they had completed specific allergy safety training.
The court was shown online modules used to train new Costa staff regarding allergens that could be accessed on a mobile phone and included a quiz trainees had to successfully complete.
Mr Abrashi confirmed that, as of February 2023, there was no requirement to complete the online modules in the presence of colleagues and they could be done at home.
He said the online training is only provided in English, with no other language options, and he, as a regional manager, would not be aware how many times a trainee had attempted the quiz before they passed.
Urmi Akter, who had been working at the Costa Coffee franchise in Barking for around eight months, took the order for the takeaway drinks from Hannah's mother and gave evidence to the inquest at an earlier hearing while seated next to a Bengali interpreter.
In a previous hearing, Emily Slocombe, representing Hannah's family, asked Ms Akter questions including whether she had been given training in her own language, if she knew what an allergen was, and also if she knew the potential consequences of being subject to any allergy.
The court was shown the training record for Ms Akter which stated she had completed the allergens safety course in September 2022.
When asked by assistant coroner Dr Shirley Radcliffe whether Mr Abrashi was aware that staff may have used Google Translate to help complete their online training, the former store manager replied: "I wasn't aware, but to me it's okay for a few words.
"To my understanding, Google Translate is used as a dictionary as well.
"It's not concerning for me.
"To my understanding, it's not that they don't know English - it's that they don't understand a certain word."
The court was shown a witness statement from a Costa barista which read: "I don't know what an allergen is but we have a book that shows us what is in our food and drinks."
Dr Radcliffe asked Mr Abrashi: "Would you expect your staff, having done the training, expect them to have an understanding of the term 'allergen'?"
"Not necessarily," he replied, adding he would expect trained staff to understand that certain ingredients could "trigger a range of symptoms" that may be fatal.
The court was told of an example where a Costa barista had failed the online quiz 20 times before passing.
Ms Slocombe asked whether someone needing to retake the test a number of times could indicate they were struggling with the language used in the training.
Mr Abrashi responded: "It tells me more that this person was trying to rush it and get to the quiz.
"I wouldn't put the understanding of English in this.
He later continued: "Having training in a different language undermines the English language.
"If they can't understand English in the first place, how would they be able to describe to the customer in English?"
The court was read a witness statement from a barista who started working at Costa in October 2022 that said: "On the first day I started behind the till taking orders, my husband came to work with me to translate.
"When reading English I use Google Translate to help me."
The witness added she had used the mobile translation app to help complete her staff training modules.
Reaction to today's ruling
The parents of a 15-year-old girl who died following a severe allergic reaction to a Pret a Manger baguette sandwich containing sesame have called for "urgent" government action to "improve understanding" of allergies across schools, businesses and society generally.
Commenting on the outcome of the inquest, Nadim and Tanya Ednan-Laperouse, co-founders of The Natasha Allergy Research Foundation, a food allergy charity, said: "We need urgent Government action to improve understanding within schools, businesses and society that food allergies can be a serious, unpredictable health condition, not a lifestyle choice, and ensure people with allergies have access to joined up and timely NHS allergy care.
"Today, along with Hannah's grief-stricken mum Abi and on behalf of other parents who have lost children to food allergies, we once again urge the Government to appoint an allergy tsar - a national champion for the one in three people who live not just with food allergies, but all types of allergic disease including asthma and eczema.
"We have written to ministers asking them to meet with us to discuss the critical issue of allergy-related deaths and the urgent need for an allergy tsar, and were disappointed to be told they were too busy.
"Today, in the light of Hannah's case and the pressing need for action, we have written to ministers again asking for an urgent meeting and are hoping that they will understand the time critical seriousness of this situation and reply with a more positive response.
"How many more children must die before we start taking food allergy seriously?"
Following Natasha's death in July 2016, the law was changed to require all food outlets to provide a full ingredients list and allergy labelling on food pre-packaged for direct sale.