Hannah Jacobs

Dr Shirley Radcliffe 
Assistant Coroner  
East London Coroner’s Court 
Queens Road  
Walthamstow 
London  
E17 8QP 

Friday 4th October, 2024 

Dear Dr Radcliffe,  

Regulation 28 Report concerning Ms Hannah Eniola Angela Ayomipo Jacobs 

Thank you for letter dated 21st August 2024 in which you asked The British Society for Allergy & 
Clinical Immunology (BSACI) to provide a response to the Regulation 28 Report to Prevent Future 
Deaths following the inquest into the tragic death of Hannah Eniola Angela Ayomipo Jacobs. 

The  British  Society  for  Allergy  and  Clinical  Immunology  (BSACI)  is  the  national,  professional  and 
academic  society  which  represents  the  specialty  of  allergy  at  all  levels.  Its  aim  is  to  improve  the 
management  of  allergies  and  related  diseases  of  the  immune  system  in  the  United  Kingdom,  through 
education, training and research. We wish to respond to all matters which fall under our remit. 

Concern 1 
“The  evidence  at  the  inquest  referred  to  allergy  action  plans  discussed  in  the  healthcare  settings  and 
given to parents and patients. Hannah displayed what appeared to be excessive salivation at the dentist 
which  her  paediatric  consultant  (who  gave  evidence)  said,  with  the  benefit  of  hindsight  was  actually  a 
manifestation of her inability to swallow. This is a sign of anaphylaxis. This was not recognised by dental 
staff as an inability to swallow and thus of anaphylaxis.” 

The  BSACI  Allergy  Action  Plans  do  state  that  difficulty  swallowing  is  a  manifestation  of  anaphylaxis. 
These plans were developed with allergy healthcare professionals and patient representatives. The BSACI 
is  developing  an  online  allergy  education  platform  for  all  healthcare  professionals  and  non-healthcare 
professionals which will include anaphylaxis. This will include the signs and symptoms and management 
approach for mild, moderate and severe allergic reactions. This will be rolled out extensively to a wide 
range  of  stakeholders.  We  would  welcome  the  involvement  of  healthcare  professionals  across  tertiary, 
secondary and primary  care  (e.g. Royal  College  of General  Practitioners, Royal  College of Nursing) in 
this  activity,  and  healthcare  leadership  (e.g.  NHS  England,  devolved  nations  heath  boards,  Integrated 
Care Boards).   

Concern 2  
“The other symptom Hannah demonstrated was swelling of her lips which is listed on allergy plans as a 
mild to moderate symptom and thus provided a false sense of reassurance to her mother that cetirizine 
was what she needed.” 

A18 
 
 
 
 
 
 
 
 
 
 
 
 
 BSACI Allergy Action Plans do state that reactions may progress from mild to moderate to anaphylaxis.  

Healthcare professionals managing patients with food allergies advise patients and their carers to always 
carry two adrenaline autoinjectors with them at all times. This is also the advice of the MHRA. This 
would include on the way to and from school. The BSACI education programme being developed aims to 
target all those who may have responsibility for people living with the risk of anaphylaxis, including 
school staff.  

Concern 3 
“The risk of future deaths in the context of anaphylaxis remains in the absence of further consideration of 
what constitutes an anaphylactic reaction as opposed a mild reaction, and the education of parents and 
patients of the safety of using AAls (adrenaline auto injectors) lF lN DOUBT.” 

The BSACI Allergy Action Plans have two boxes that clearly list the symptoms and signs of firstly a mild 
or moderate reaction and secondly anaphylaxis. These were developed with a wide range of healthcare 
professionals and patient groups. Additionally, plans state “if in doubt, give adrenaline”.  

As mentioned BSACI are developing an online allergy education platform for all healthcare professionals 
and non-healthcare professionals, which will include anaphylaxis, specifically its recognition and 
management. This will be rolled out extensively to a wide range of stakeholders.   

BSACI  has  collaborated  with  patient  organisations  to  develop  guidelines  and  information  leaflets.  This 
includes  an  Anaphylaxis  patient  information  leaflet  which  can  be  viewed  here.  This  clearly  states  the 
signs and symptoms of anaphylaxis and is accessible to all patients. 

Concern 4 
“I was made aware there had been a shortage of AAI at the time, but a vial of adrenaline was available 
at the chemist. However, it takes time to draw up. I am not sure if (assuming no national shortage) all 
chemists have AAI in stock for emergencies.” 

BSACI is unable to comment on this point. 

We trust that this letter addresses the concerns that have been raised in your report, however, please do 
contact us should you require any further information.  

Your sincerely, 

President – British Society for Allergy & Clinical Immunology  

A19

ggdc 
gdc-uk.org 

BY EMAIL: 

East London Coroner's Court,  
Queens Road,  
Walthamstow,  
E17 8QP 

14 October 2024  

Dear Dr Radcliffe,  

RE: Regulation 28 Report to Prevent Future Deaths Report  

I write in response to your Regulation 28 Report to Prevent Future Deaths (the Report) dated 20 
August 2024 in respect of the inquest into the death of Miss Hannah Eniola Angela Ayomipo 
Jacobs.   

This is a tragic case, and it is the great sadness that I learnt of Hannah’s death.  I extend my 
sincere condolences to Hannah’s family and loved ones.   

I note that you have expressed concern in relation to the circumstances that arose when Hannah 
attended at a dental surgery on 8 February 2023. Hannah began to show symptoms of 
excessive salivation in the dentist’s room, which, in hindsight, was not recognised by dental staff 
as the early symptoms of an anaphylactic reaction brought on by an inability to swallow. Hannah 
refused treatment and was rushed to the pharmacist by her mother.   

I have carefully considered the standards that we set and guidance that the General Dental 
Council (GDC) provides for the dental team as relevant to these events, and whether further or 
different standards or guidance are required or whether there is any further action which the 
GDC should consider.    

The Role of the GDC  

The  GDC  is  the  UK-wide  statutory  regulator  of  dentists  and  dental  care  professionals.  Our 
overarching objective is the protection of the public. To achieve this, we register qualified dental 
professionals, quality assure the standards of dental education, set standards and issue guidance 
for the dental team and investigate complaints about dental professionals' fitness to practise.  

Although  we  have  some  regulatory  responsibility  for  how  businesses  that  practise  dentistry  is 
constituted, dental premises are regulated by the Care Quality Commission.   

The GDC sets standards and issues guidance that are relevant to how dentists are prepared for 
and respond to medical emergencies when they arise. The GDC also endorse the standards and 
guidance set by other organisations that are applicable to dental professionals. The framework of 
standards and guidance that is applicable to the events that took place on 8 February 2023 is set 
out below.   

37 Wimpole Street London W1G 8DQ 

A10 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ggdc 
gdc-uk.org 

GDC standards and requirements  

The GDC sets requirements, Preparing for Practice, for the learning outcomes which UK training 
courses must achieve where the resulting qualification is the basis for allowing people to register 
as dental professionals. It sets a general requirement that “Students must be trained in accordance 
with appropriate requirements in relation to dealing with medical emergencies.” There is also a 
specific requirement for each of the dental professional groups, with dentists require to be able to 
“identify, assess and manage medical emergencies.”  

The GDC also set standards for registered dental professionals, Standards for the Dental Team. 
These are standards that set out the conduct, performance and ethics that are expected of the 
dental team.   

The  following  standards  are  relevant  to  how  dentists  are  prepared  for  and  respond  to  medical 
emergencies.   

Standard 1.5 sets out “You must treat patients in a hygienic and safe environment” and requires 
the dental team to follow the guidance on medical emergencies and training updates issued by 
the Resuscitation Council (UK) (Standard 1.5.3).  

Standard 7.1 obliges dental professionals to provide good quality care based on current evidence 
and  authoritative  guidance,  including  an  obligation  to  find  out  about  current  evidence  and  best 
practice  that  affects  their  work,  premises,  equipment  and  business  and  follow  them  (Standard 
7.1.1). This standard also obliges dental professionals who have not followed established practice 
and guidance to explain why (Standard 7.1.2).  

The effect of the Standards   

The  effect  of  Standard  1.5  is  that  members  of  the  dental  team  are  obliged  to  follow  the 
Resuscitation Council UK guidance on medical emergencies and training updates (the RCG). If 
they do not, and a concern was raised with the GDC, this might result in regulatory proceedings 
to examine their fitness to practise dentistry.   

Any  concerns  raised  with  the  GDC  are  considered  carefully  in  accordance  with  our  Fitness  to 
Practise Rules and regulatory framework.  

The RCG sets out the quality standards that apply to healthcare organisations. This includes an 
obligation  to  provide  a  high-quality  resuscitation  service  and  ensure  that  staff  are  trained  and 
updated  regularly  to  a  level  of  proficiency  appropriate  to  everyone’s  expected  role.  The  RCG 
includes a list of primary care equipment that must be available. The list includes adrenaline.  

The GDC also provides further guidance to registrants on our website which is linked here. This 
page provides a link to the RCG and additionally sets out an obligation on all registrants that they 
must be trained in dealing with medical emergencies and possess up to date evidence of capability 
within the scope of their role.   

As part of the guidance, we signpost further guidance provided by the National Institute for Health 
and Care Excellence (NICE) for dental professionals. This includes a list of medication that must 
be included in an emergency drugs kit in a dental practice set out in the British National Formulary. 
This list contains adrenaline/epinephrine. NICE also provides guidance to dental professionals on 
the management of common medical emergencies.  

37 Wimpole Street London W1G 8DQ 

A11 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ggdc 
gdc-uk.org 

There  is  specific  guidance  from  NICE  regarding  how  dental  professionals  should  deal  with 
anaphylactic  reactions.  It  provides  information  about  how  anaphylactic  reactions  may  arise, 
outlines that they may be associated with additives and excipients in food and lists the common 
symptoms and signs of anaphylaxis. The list of symptoms does not, however, include excessive 
salivation. This was the symptom displayed by Hannah on the premises. The guidance goes on 
to inform dental professionals that the first line treatment for anaphylaxis is the administration of 
intramuscular adrenaline/epinephrine.  

The effect of Standard 7.1 is that dental professionals are obliged by the GDC to provide good 
quality  care  based  on  current  evidence  and  authoritative  guidance  and  follow  best  practice  or 
explain why they have not done so, if required. Current guidance includes the NICE guidelines 
which are specifically referenced within the GDC guidance on our website, as set out above.   

In  addition,  the  GDC  recommends  that  dental  professionals  complete  at  least  10  hours  of 
continuing professional development in relation to medical emergencies, in each five-year CPD 
cycle and at least two hours of this type of activity every year.   

Other Standards  

The Care Quality Commission (CQC) regulates dental premises, and the Health and Social Care 
Act 2008 (Regulated Activities) Regulations 2014 are applicable. The CQC requires that a provider 
must  have  arrangements  in  place  to  take  appropriate  action  if  there  is  a  medical  emergency 
(Regulation  12(2)(b))  and  that  providers  must  have  sufficient  medication  available  in  case  of 
emergencies (Regulation 12(2)(f)).   

Further action  

I  have  carefully  considered  the  applicable  guidance  and  standards  and  whether  different  or 
additional guidance or standards are required.   

The  current  framework  of  standards  and  guidance  sets  out  clear  obligations  for  dental 
professionals to have appropriate training and keep medication on their premises to use in the 
event of a medical emergency. I think that it is appropriate to continue to require adherence to the 
RCG as set out at Standard 1.5 and other appropriate guidance, including the NICE guidance as 
set out in Standard 7.1.  

Whilst  I  note  your  concern  that  dental  professionals  did  not  recognise  the  early  symptoms  of 
anaphylaxis,  I  also  note  that  the  symptom  of  excessive  salivation  is  not  listed  as  a  potential 
symptom in the NICE guidance. We will write to NICE to highlight this, and to ask them to consider 
reviewing  the  listed  symptoms  of  anaphylaxis  and  their  guidance  to  dental  professionals  more 
broadly.  

We are currently in the process of reviewing our CPD requirements, and we will consider whether 
we should propose changes to the recommendations regarding medical emergencies as part of 
the review.  The review is expected to conclude in 2025, but some potential changes would require 
legislative changes, the timing of which is not under our control.  

37 Wimpole Street London W1G 8DQ 

A12 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ggdc 
gdc-uk.org 

Should  you  require  any  further  information  in  respect  of  the  role  of  the  GDC,  our  Standards, 
requirements  for  Continuing  Professional  Development  or  our  Fitness  to  Practise  processes, 
please do not hesitate to contact me.   

Yours faithfully, 

Chief Executive & Registrar  

37 Wimpole Street London W1G 8DQ 

A13

Dr Shirley Radcliffe 
Assistant Coroner for the coroner area of East London 

By email via: 

15 October 2024 

Dear Dr Radcliffe 

Re: In the matter of Hannah Eniola Angela Ayomipo Jacobs (ref: 21836270) 

Thank you for sending us the two Regulation 28 reports regarding the death of Hannah Eniola Angela 
Ayomipo Jacobs. We are very sorry to hear about this sad death and we would like to pass on our 
sincere condolences to Hannah’s family.  

By way of background, the GPhC is the independent regulator for pharmacists, pharmacy technicians 
and pharmacies in Great Britain. Our main job is to protect, promote and maintain the health, safety 
and wellbeing of members of the public by upholding standards and public trust in pharmacy. This 
includes maintaining a register of pharmacy professionals and premises, setting regulatory standards 
and investigating concerns. 

We are aware of ongoing and intermittent supply issues with adrenaline autoinjectors (AAIs) which have 
been lasting for several years. While we do not have a direct role in the manufacturing of medicines or 
wider issues such as supply and shortages, we understand that medicines shortages can cause problems 
for patients, carers and those supporting people living with life-threatening allergies requiring 
adrenaline.  

We know that pharmacy professionals are also concerned and having to use their professional 
judgement and make decisions in challenging situations, balancing a range of factors such as individual 
patient needs and available supplies of medicines. 

Our standards require pharmacy professionals to deliver patient-centred care, which includes making 
the care of the patient their first concern and using their judgement to make professional decisions. This 
may include making decisions about providing medication in an emergency. 

pharmacyregulation.org | info@pharmacyregulation.org |020 3713 8000 

A1 
 
 
 
 
 
 There are no requirements for registered pharmacies to routinely stock AAI’s unless they are providing 
services which specifically require adrenaline to be available in case the patient suffers an anaphylaxis 
reaction. An example would be the seasonal influenza vaccination service.   

For such services the adrenaline does not have to be available as an AAI and can be kept in other 
medicinal forms such as ampoules for injections. 

Specific enquiries about the availability of particular medicines, can be directed to the medicines supply 
team at the Department of Health and Social Care (DHSC) on 
manufacturers and wholesalers, they would be best placed to help answer any questions you may have 
regarding the availability of medicines. 

. Alongside 

Additionally there are other supportive resources available, such as the  guidance and resources for safe 
use of adrenaline auto-injectors produced by Medicines Healthcare products and Regulatory Agency 
(MHRA). This contains advice for healthcare professionals and advice for them to provide to patients 
and their carers on safe usage of AAIs.  

We hope this information is helpful. If you should require any further information, please do not 
hesitate to contact me. 

Finally, I would like to extend an invitation to Hannah’s family to meet with me and our Chief Pharmacy 
Officer, 
contact details.  

, if that would be helpful in any way. Please do pass on our invitation and share my 

Yours sincerely, 

Chief Executive and Registrar  

A2

Dr Shirley Radcliffe  
Assistant Coroner  
East London Coroner’s Court  
Queens Road  
Walthamstow 
London  
E17 8QP 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

14 October 2024  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Hannah Eniola Angela 
Ayomipo Jacobs who died on 8 February 2023  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  20 
August  2024  concerning  the death of  Hannah  Eniola  Angela  Ayomipo  Jacobs  on  8 
February  2023.  In  advance  of  responding  to  the  specific  concerns  raised  in  your 
Report, I would like to express my deep condolences to  Hannah’s family and loved 
ones. NHS England are keen to assure the family and the coroner that the concerns 
raised about Hannah’s care have been listened to and reflected upon.   

I respond to each of the concerns raised in your Report below.  

1. The evidence at the inquest referred to allergy action plans discussed in the 
healthcare settings and given to parents and patients. Hannah displayed what 
appeared  to  be  excessive  salivation  at  the  dentist  which  her  paediatric 
consultant  (who  gave  evidence)  said,  with  the  benefit  of  hindsight  was  a 
manifestation of her inability to swallow. This is a sign of anaphylaxis. This 
was  not  recognised  by  dental  staff  as  an  inability  to  swallow  and  thus  of 
anaphylaxis.  

Saliva secretion is dependent on autonomic nerve signals, which are stimulated by the 
smell, taste, and chewing of food. In this tragic case it could be reasonable to assume 
that  Hannah  had  hypersalivation  in  response  to  her  chocolate  drink  and  that  her 
distress would also alter her salivary rate.  

The  Resuscitation  Council,  the  UK’s  national  expert  in  resuscitation  and  the 
organisation whose guidelines form the basis of anaphylaxis management in the UK, 
do not list excess salivation as a sign or symptom of anaphylaxis. It is therefore not 
unreasonable that the dentist or dental team did not assume early anaphylaxis from 
hypersalivation.  

2.  The other symptom Hannah demonstrated was swelling of her lips which is 
listed on allergy plans as a mild to moderate  symptom and thus provided a 
false sense of reassurance to her mother that cetirizine was what she needed.  

                                                                                                                       
 
 
 
 
 
 
  
 
 
  
 The allergy plans from the British Society of Allergy and Clinical Immunology (BSACI), 
a national academic society  whose core aim is to improve allergy care by providing 
allergy  resources  for  healthcare  professionals,  including  clinical  guidelines  and 
educational  meetings,  states  that  reactions  may  progress  from  mild  and  moderate 
symptoms to anaphylaxis. This is also explicitly stated in the Resuscitation Council UK 
Guideline  for  healthcare  practitioners.  It  is  expected  that  clinicians  make  this  clear 
when discussing the plans with families of children with severe allergies.  

Action plans also advise not to stand up a child in the case of a severe reaction and 
make  clear  to  use  adrenaline,  whenever  in  doubt  as  to  the  severity  of  a  reaction. 
Standard  teaching  practice  accompanying  these  plans  is  that  where  there  is 
uncertainty, the default should be to use the  adrenaline auto-injectors (AAI). This is 
also supported by guidance from the Medicines and Healthcare Products Regulatory 
Authority (MHRA).  

3. The risk of future deaths in the context of anaphylaxis remains in the absence 
of  further  consideration  of  what  constitutes  an  anaphylactic  reaction  as 
opposed to a mild reaction, and the education of parents and patients of the 
safety of using AAls (adrenaline auto injectors) if in doubt.   

Significant  stakeholder  consultation,  including  with  patients  of  all  ages  (including 
children),  their  families,  schoolteachers  and  other  lay  individuals  informed  the 
Resuscitation Council UK Guideline and the BSACI plans guidance on what may be 
considered as possible indications of anaphylaxis, and the ‘if in doubt’ message to use 
AAI wherever there might be uncertainty.  

Any additions to the plan must be carefully balanced with the existing  messaging to 
ensure  there  is  no  risk  of  detracting  from  the  key  headline  symptoms  and  the  ‘if  in 
doubt’ message.  

4. There was shortage of AAI at the time but a vial of adrenaline was available 
at the chemist. However, it takes time to draw up. I am not sure if (assuming 
no national shortage) all chemists have AAI in stock for emergencies.  

The shortage of AAI has been resolved.  At the time Hannah went into anaphylaxis, 
there was a shortage of Jext and a recall of Emerade, both of which are AAIs.  

My Patient Safety colleagues in North East London have confirmed that community 
pharmacies were notified of the shortage of Jext, however they have not been able to 
confirm  if  the  same  message  was  sent  to  all  GPs.  They  are  therefore  currently 
reviewing their communications approach to alerting GP practices. The Pharmacy and 
Medicines Optimisation Team do include updates from the MHRA in their newsletters 
along with a link to Medicines Supply Tool – SPS - Specialist Pharmacy Service – The 
first stop for professional medicines advice and this provides information on national 
shortages and how to manage them. 

The Pharmacy and Medicines Optimisation Team have been reviewing the use of AAIs 
and  their  supply.  The  detail  of  this  work  is  still  being  finalised  but  my  regional 
colleagues in London have been asked to ensure the national team are provided with 
updates on this work.   

 I would also like to provide further assurances on national NHS England work taking 
place around the Reports to Prevent Future Deaths. All reports received are discussed 
by  the  Regulation  28  Working  Group,  comprising  Regional  Medical  Directors,  and 
other clinical and quality colleagues from across the regions. This ensures that key 
learnings and insights around events, such as the sad death off Hannah, are shared 
across  the  NHS  at  both  a  national  and  regional  level  and  helps  us  to  pay  close 
attention to any emerging trends that may require further review and action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

National Medical Director

Dr Shirley Radcliffe 
East London Coroners Court  
Queen’s Road, Walthamstow 
E17 8QP  

2 January 2025 

Sent by email to: 

Dear Dr Radcliffe, 

Re: RCPCH Response to the Inquest Touching the Death of Hannah Jacobs 
A Regulation 28 Report – Action to Prevent Future Deaths 

Thank you for sharing your report with us regarding the tragic and untimely passing of 
Hannah Jacobs. I was very sorry to hear of Hannah’s death. I have shared your report with 
other senior paediatric colleagues within RCPCH, namely our Officers for Clinical Standards 
and Quality Improvement. We have read your report carefully and note the following RCPCH 
activity in relation to the matters of concern.  

As the Royal College of Paediatrics and Child Health, we are primarily responsible for the 
education and training of paediatricians across the UK. We are not involved in the training of 
dentists and dental staff and have no role in the supply of epi-pens to pharmacies. As part of 
our training, we run CPD courses on child health topics that are of interest and relevance to 
the wider child health workforce. This includes Paediatric Allergy Training study days that 
focus on the practical clinical management of allergy in children and young people. These 
courses are suitable for all professionals seeing children with allergic disease. You can read 
more about these courses on our RCPCH Learning platform. We will ensure these continue 
to be widely promoted across the child health workforce.  

Our training curriculum has the following competency which is relevant to this case: 
“Recognises and manages the acute presentations and after-care of anaphylaxis, 
prescribing and training the family to use adrenaline autoinjectors, including documenting 
events and producing an emergency action plan with appropriate onward referrals.” 

The College also has a role in providing paediatric clinical guidelines and standards. 
Relevant to this matter would be our allergy care pathways which are signposted clearly on 
our website.  

The College will be sharing information and suggestions for local improvement from your 
report with our paediatric members via its patient safety portal. The anonymised information 
within your report will also be shared for discussion with the RCPCH Clinical Quality in 
Practice Committee, where further actions may be identified.   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Thank you for seeking our views and reminding us of the importance of this work. Our 
sincere condolences are with Hannah’s family.  

Yours sincerely 

RCPCH President

Care Quality Improvement Directorate 
Royal College of Physicians  
The Spine 2 Paddington Village  
Liverpool  
L7 3FA  
Tel: 
Email: 
www.rcp.ac.uk  

T: 

Dr Shirley Radcliffe 
Assistant Coroner 
East London Coroner’s Court 
Queens Road 
Walthamstow  
E17 8QP 

T: 

11 October 2024 

Dear Dr Radcliffe 

Report to prevent future deaths Hannah Eniola Angela Ayomipo Jacobs 09.10.2024  

The Royal College of Physicians (RCP) notes with concern the content of the Regulation 28 
report for the prevention of future deaths related to the death of Hannah Eniola Angela 
Ayomipo Jacobs. 

We send our sincere condolences to the family of Hannah Eniola Angela Ayomipo Jacobs.  

The Regulation 28 report is addressed to the President of the Royal College of Physicians 
but we note that Hannah was 13 years old, and therefore her care would be part of 
paediatric services, rather than adult services. However, RCP holds a Joint Committee on 
Immunology and Allergy that brings together professional leads in allergy for adult services. 
In addition the RCP hosts the IQAS accreditation programme for adult allergy services that 
develops standards for allergy services, and accredits services for achieving these 
standards.  

Sadly the key elements outlined in this tragic case have also been outlined in previous 
Regulation 28 notices when people have died from the preventable effects of acute allergic 
reactions. The dominant issues in Hannah’s case were the recognition of 
allergic/anaphylactic reaction by the patient, parent and health professionals, and the 
carrying and use of self administered adrenaline when anaphylaxis may be occurring.  

These elements need to be addressed through 

•  Adequate provision of allergy services across the UK for both adults and children. 
This will be important as part of NHS England and other nations workforce plans. 

A14 
 
  
 
 
 
 
 
 
 
 
 
 
 
 •  Education of healthcare professionals in all sectors on recognition diagnosis and 
management of allergy and anaphylaxis, including the carrying and use of self 
administered adrenaline.  

•  National leadership for allergy within the NHS and across sectors that can contribute 

to reducing the risk for patients and populations.  

The RCP will work with Royal College of Paediatrics and Child Health, Royal College of 
Pathologists, British Society for Immunology – Clinical Immunology Professional Network, 
British Society for Allergy and Clinical Immunology, dental and pharmacy professional 
groups, to agree and support standards of care and education related to allergy. This will 
include updating standards for allergy accreditation, including the adoption of the BSACI 
adult allergy action plan where many of the aspects related to this case are addressed 
including carrying adrenaline autoinjectors, and difficulty in swallowing is an indication for the 
use of adrenaline. 

The RCP will continue to highlight the importance of education (around self-management 
and allergen avoidance) and access to service user support groups for services registered 
and accredited with IQAS, and more widely.  

We will also continue to promote multidisciplinary care for people with allergy including 
dietetic support. As a member of the expert advisory group on allergy (EAGA) the RCP is 
working on the development of the UK National Allergy Strategy. The UK National Allergy 
Strategy aims to provide a collaborative approach to improving health outcomes and other 
unmet needs of the allergic community across the UK. 

Yours sincerely 

Clinical Vice President 

A15