A mother of five with an acute dairy allergy has died after eating a vegan Pret a Manger wrapper contaminated with traces of milk, a coroner has found.
Celia Marsh, 42, a dental nurse from Melksham, Wiltshire, suffered anaphylaxis shortly after eating a super vegan rainbow flatbread from the chain store in Bath on December 27, 2017.
Coconut yoghurt used as a topping from Australian brand CoYo, which was licensed to UK-based Planet Coconut for manufacturing in the UK, had traces of milk protein, lead coroner Maria Voisin concluded.
Ms Voisin reached a narrative conclusion on Thursday following a two-week inquest into Ms Marsh’s death at Avon Coroner’s Court in Bristol.
He said the maker of the yogurt, which is labeled dairy-free, had documentation outlining the risk of cross-contamination but did not pass on the information to customers.
The coroner said: “Celia Marsh was allergic to milk. She died of anaphylaxis caused by consuming a wrap contaminated with milk protein.
“She didn’t know the wrapper contained milk protein. The wrapper contained a product that was labeled as a dairy-free alternative to yogurt, but nevertheless contained milk protein that was the cause of Celia’s anaphylaxis.
“The contamination arose because a yogurt ingredient called HG1 (a starch) had been cross-contaminated with milk protein during manufacturing.
“The manufacturer of the dairy-free yogurt had documentation in their possession indicating this risk, but this risk was not passed on to their customers.”
The inquest has previously heard that the mother of five avoided all dairy products following a near-fatal allergic reaction a few months earlier in which she required 15 injections of adrenaline.
Mrs. Marsh had been on a post-Christmas shopping trip with her husband and three of their daughters when she went to Pret to get something to eat around 2 p.m.
She was pronounced dead less than two hours later.
The wrapper had been consumed in its entirety, and the jar of CoYo brand yoghurt used to make it was thrown away before Bath and North East Somerset Council began their investigation.
But tests in other pots found trace amounts of milk protein in the product, with traces found in another rainbow wrapper.
During the two-week investigation, a chemist acknowledged that the amount of dairy in the wrapper was too low to measure with any degree of precision, but said he believed it definitely contained milk.
The contamination is believed to have come from the HG1 starch in the yogurt.
Speaking after the conclusion of the inquest into her mother’s death, Ashleigh Grice criticized the food industry for relying on “vague” food labeling regarding allergens, rather than implementing a strict testing regimen.
Ms Grice also criticized the maker of the vegan yoghurt that was contaminated with trace amounts of milk for not informing Pret a Manger of the allergen risk.
“It is now clear to us that if Planet Coconut had passed on the warnings they had to Pret a Manger about the risk of cross-contamination, Mom would still be alive today,” she said.
“Mom’s death, like so many other allergy deaths, was completely preventable.”
Pret a Manger CEO Pano Christou said: “As a father and husband, I can only imagine how harrowing this has been for Celia’s children and family. Our deepest condolences go out to all who knew and loved Celia.
“We fully support the coroner’s findings. As the coroner made clear, Planet Coconut had information that should have alerted them that their Coyo yogurt might have contained milk and this information was not passed on to Pret.
“It goes without saying that if Pret had ever known that Coyo yogurt might have contained milk, we would never have used the ingredient.
“On Pret’s part, we have taken significant steps with our suppliers and labeling policies since 2017.”
Ms Marsh’s death followed that of 15-year-old Natasha Ednan-Laperouse, who died in 2016 after eating a Pret baguette containing sesame seeds.
Mrs. Ednan-Laperouse had a sesame allergy.
The tragedy prompted a review of food labeling laws.
Retailers are now required to display the full ingredient and allergen label on every food made on the premises and prepackaged for direct sale, including sandwiches, pastries and salads.
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