A coroner has called for a robust system of recording serious cases of anaphylactic shock following the death of a woman who died after eating a Pret a Manger sandwich.

Celia Marsh, 42, who had an acute dairy allergy, ate a super veg vegan wrap contaminated with milk from the sandwich chain’s Bath store.

The yoghurt dressing in the wrap was later found to be contaminated with traces of milk protein stemming from a starch manufactured in a facility handling dairy products.

Maria Voisin, senior coroner for Avon, made several recommendations in a preventing future deaths report following an inquest into Mrs Marsh’s death, including improved reporting of anaphylaxis incidents and a robust system to ensure food labelling is current.

The report has been sent to several organisations, including the Food Standards Agency, the UK Health Security Agency, the Department of Health and Social Care, the British Retail Consortium and the Food and Drink Federation.

In the report, Ms Voisin highlighted her wish for the establishment of a “robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individuals by products with undeclared allergen content.”

Celia Marsh inquest
Celia Marsh died after eating a sandwich contaminated with milk (Leigh Day/PA)

She went on: “Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases, including some food-borne illnesses, whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases.”

Ms Voisin also emphasised her concerns about the public’s understanding of the wording used on certain foods, such as “free from” and “vegan”.

“Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim,” she said.

“With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled ‘free-from…’ may not be safe to consume.”

Celia Marsh inquest
Andy Marsh with his wife Celia Marsh (Leigh Day/PA)

The inquest, which concluded in September, heard Mrs Marsh died on December 27 2017 after eating the wrap.

The mother-of-five, a dental nurse from Melksham, Wiltshire, purchased the wrap at 2.08pm, and within 15 minutes entered into acute anaphylactic shock. She was declared dead at 4pm.

The wrap contained a coconut yoghurt dressing from Australian brand CoYo, which was licensed for manufacture in the UK to British firm Planet Coconut.

An ingredient in the yoghurt, a starch called HG1, had been cross-contaminated with milk protein during its manufacture.

Mrs Marsh’s family said they welcomed the publication of the coroner’s report “as the next step in our fight to make the world a safe place for allergy sufferers like our beloved mum and wife.”

They added: “Above all, we hope that the Food Standards Agency, UK Health Security Agency and the Department of Health and Social Care will now start working together to put in place a system for mandatory reporting of fatal and near fatal anaphylactic reactions to allow the public to be alerted of unsafe allergen products and provide an accurate record of such incidents.

“This will ensure important lessons can be learned with the appropriate enforcement action being taken.

“The coroner has required responses from a wider range of organisations, and we very much hope that those organisations consider and take action on these suggestions as soon as possible.”

Michelle Victor, from law firm Leigh Day which represents the Marsh family, said: “It is crucial that all those receiving the report act on it as soon as possible to make sure that allergy sufferers can be confident that the products they eat are safe, and to make sure that any serious and fatal incidents of anaphylaxis are properly and thoroughly recorded and investigated.”

Mrs Marsh’s death came in the wake of that of 15-year-old Natasha Ednan-Laperouse, who died in 2016 after eating a Pret baguette containing sesame seeds bought at Heathrow Airport.

The tragedy sparked an overhaul of food labelling laws which now requires retailers to display full ingredient and allergen labelling on every food item made on the premises and pre-packed for direct sale, including sandwiches, cakes and salads.