A “national shortage” of adrenaline auto-injectors contributed to the death of a child who collapsed in a pharmacy after having a severe allergic reaction to dairy – leaving a pharmacist unable to give her the dose she needed, a London coroner has found. 

Thirteen-year-old Hannah Jacobs of East London, who was severely allergic to eggs, wheat and dairy, died on February 8, 2023 after she and her mother had bought two hot chocolates at a branch of Costa in Barking on their way to a dental appointment, believing the drinks to contain soya. 

However, “due to a failure of communication and a failure to follow the correct allergy process” they were served drinks containing dairy, assistant coroner for East London Shirley Radcliffe said in her report to prevent future deaths, which was published recently. 

While they were at the dentist, Hannah took a sip from her drink and “developed symptoms of excessive saliva,” after which she and her mother rushed to Daynight Pharmacy, which across the road from the dental surgery. 

She had been prescribed both antihistamines and an EpiPen to manage her allergy, but neither she nor her mother were carrying the prescribed auto-injector.

At the pharmacy, Hannah’s mother asked for cetirizine, which was “given to no effect”.

The coroner’s report adds: “Then she asked for an Epi-Pen but due to a national shortage there was only one in stock, a 150mcg rather than the 500mcg Hannah had been prescribed.  

“This was given but sadly Hannah went into cardiac arrest and could not be resuscitated.”

The coroner noted that while there was a shortage of auto-injectors at the relevant time, the pharmacy did have a vial of adrenaline; “however, it takes time to draw up”. She queried whether all pharmacies have auto-injectors “in stock for emergencies”. 

The report was sent to health bodies including the General Pharmaceutical Council, General Dental Council, NHS England and the Royal College of Paediatrics, all of whom are required to issue a response. 

Copies were also sent to Hannah’s family as well as Costa Coffee.