The last time I saw my big sister Celia was at our leaving party in July 2017, five months before she died. My family were uprooting from the UK to Melbourne, Australia and I remember thinking how healthy she looked – she’d been working on her fitness and, as an allergy sufferer, she was getting to grips with her dairy-free lifestyle. She was full of life and looking forward to visiting us in our new home soon.
But on 27 December that year, Celia went on a family shopping trip to the Bath Christmas sales and tragically died of anaphylaxis as a result of consuming a contaminated dairy-free vegan rainbow vegetable wrap purchased from Pret a Manger.
Celia was highly allergic to dairy and religiously avoided it in her diet. The wrap she consumed on that fateful day contained dairy, which caused her death.
I had booked to go on a camping trip and we were traveling there on a country road when my phone started ringing. When I picked up, I heard the devastating news from Andy, Celia’s husband.
I was already aware of the severity of her adult-onset milk allergy since she’d suffered a first anaphylactic reaction in May 2017. Eating a cereal bar almost killed her – demonstrating just how severely allergic she had become.
Since that incident, I felt some comfort in knowing she was so meticulous and careful about everything she ate.
Upon hearing the tragic news of her death, I was in disbelief and could not understand how the incident had occurred. I remember feeling very numb and shocked by what had happened and felt quite useless on the other side of the world.
When I spoke to Andy a few days later, we spoke about how careful Celia was when choosing what she could eat and spotting milk on ingredient lists. We knew she would not have made a mistake and vowed to uncover the truth and identify the source of the dairy contamination in the wrap.
On 22 September 2022 – more than four-and-a-half years on – the coroner at her inquest ruled that her death was from anaphylaxis caused by the milk protein found in the contaminated dairy-free yoghurt used in the wrap.
I flew back to the UK from Australia for the inquest and know how difficult and emotional it was for the whole family. The details that came out in statements were shocking and upsetting. The driver for me was understanding the truth of what happened.
Before hearing the details at the inquest, I had little appreciation of how unregulated the food standard was for ‘free-from’ products.
As details emerged of the lack of due diligence and testing carried out, I felt my anger grow at almost everything Bethany Eaton – the founder and managing director of Planet Coconut, who provided the contaminated yoghurt to Pret a Manger – was saying. She repeatedly stated she “trusted” the verbal assurances from Henry Gosling, the director of Coyo in Australia, that his HG1 stabiliser product was dairy-free.
The wording on the 25kg bags of the stabiliserdelivered to Planet Coconut’s factory spelled out that the product had been “manufactured in a factory that handles milk”. Eaton said it didn’t surprise her that allergens were handled in the facility, but that she had been assured the product was being made in a separate area that was dairy-free. We were not provided with documentary evidence corroborating this assertion.
Celia and I grew up in the small town of Hungerford in Berkshire and as a child I knew she had some mild eczema and hay fever but other than that she had no food allergies. Celia was a great big sister throughout her life. I also remember the comforting feeling when starting primary school knowing that Celia was there to look after me and that made me feel safe and protected.
Now that the inquest is over, our family, supported by Michelle Victor and Angela Bruno and their team from Leigh Day solicitors, want to see change for Celia.
The coroner’s ruling was comprehensive and just, and gave us all validation.
The coroner made clear that Planet Coconut had in their possession documents that flagged the risk of cross contamination, but this risk was not passed up the supply chain to Pret. Pret confirmed that if it had ever known that the yoghurt may have contained milk, it would never have used the ingredient. In other words, Celia would have been alive today.
I take some comfort in believing Celia’s death will not be in vain. The coroner has confirmed she will be providing a prevention of future deaths report to highlight suggestions made during Celia’s inquest to protect allergy sufferers. This brings us considerable hope that change is on its way.
One main consideration is whether a system of obligatory testing for all ingredients in a supply chain should be implemented.
‘Free-from’ should mean a guaranteed total absence of the allergen from the food and not be an interpretation by the manufacturer, with no requirement to test the product to ensure it has not been contaminated.
Celia’s death could have been prevented by a regulated requirement of testing and a mandated safety standard to verify the free-from claim.
There should be a free-from certification mark that can be earned and applied to products to show regular testing, auditing and controls. The certification would provide a visible assurance that the product has been assessed to the BRCGS standard and that the claim is rigorously verified and maintained.
Allergy suffers should not have to gamble with their lives every time they eat outside the house or try a product that claims to be safe and free-from allergens.
Awareness and guidance for food allergy sufferers also needs to improve. This could include guidance for allergy suffers to inform them of the meanings of specific labelling and the associated risks introduced by the lack of regulation standards, alongside an undefined food safety benchmark.
In Victoria, in Australia, all anaphylaxis cases presenting to hospital for treatment should be reported to the Department of Health. This process ensures samples and evidence are taken immediately to identify the source of the reaction and uncover any possible dangers to other allergen sufferers. The coroner has recommended food-related anaphylaxis should be registered as a notifiable disease in the UK, which would serve the same purpose.
All teachers and school staff in Australia are trained in anaphylaxis identification and response, as well as the correct use of auto-injector adrenalin pens. Schools keep stock of multiple pens in first aid kits to respond quickly to anaphylaxis emergencies.
Food labelling in Australia is generally better than the UK, with all allergens identified using Voluntary Incidental Trace Allergen Labelling (VITAL) that provide a standardised and audited allergen risk assessment process for food industry.
There is, however, no need for food business operators to wait for the coroner’s final report, or for the Food Standards Agency to consult on implementation. We have the knowledge of how and why Celia died, and food companies should be acting now. What is good for their customers is good for their business. It is also the right thing to do.
As Celia’s younger brother, I miss the feeling of having her looking out for me. She always had time for me and was so supportive. She would bring her smile wherever she went and loved to help others.
She would take some comfort in knowing the cause of her death was being used to deliver improvements in the lives of all food allergy sufferers.
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