Girl, 13, died after single sip of Costa hot chocolate due to staff's 'failure to follow processes'
17 August 2024, 10:44 | Updated: 17 August 2024, 17:17
The death of a 13-year-old girl who died after having a severe reaction to a Costa hot chocolate was due to staff's "failure to follow processes" and a “failure of communication”, a coroner concluded.
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Hannah Jacobs, who had been allergic to dairy products, fish and eggs since she was a toddler, died within hours of taking a sip of the drink on February 8, 2022, East London Coroner's Court was told.
The schoolgirl, from Barking, east London, suffered an "immediate reaction" after just one sip of the hot chocolate, that was supposed to be made with soya milk, the inquest heard.
On Friday, the inquest concluded that Hannah had died after a "failure to follow the processes in place to discuss allergies", and a "failure of communication" between the coffee shop staff and Hannah's mother, Abimbola Duyile.
Assistant coroner Dr Shirley Radcliffe said: "The root cause of this death is a failure to follow the processes in place to discuss allergies combined with a failure of communication between the mother and the barista."
Following the inquest, Ms Duyile said allergen safety training should not be treated as a "tick-box exercise".
A member of her legal team read a statement outside East London coroner's court on her behalf, saying: "Having heard all the evidence over the last week, it is clear to me that although the food service industry and medical professionals are required to have allergy training, the training is really not taken seriously enough.
"Better awareness is really needed in these industries and across society of the symptoms of anaphylaxis.
"Allowing people who serve food and drinks to retake an allergy training test for 20 times is not acceptable.
"Treating allergy training as a tick-box exercise is not acceptable, being a medical professional and not reacting quickly to even a possible anaphylactic reaction is not acceptable, and the consequence of all of this is that my daughter is no longer here."
Despite Costa's allergy training instructing staff to show an "allergy book" to customers who report allergies, Costa employee Urmi Akter who served Ms Duyile did not do so, the hearing was told.
The inquest previously heard that, at the time of Hannah's death, allergen training for new Costa staff involved a series of online modules that could be accessed at home, and a quiz that trainees had to pass.
During the inquest, the court heard evidence from Costa staff about their training on food safety and allergens.
The court heard written evidence from Costa employees, one of whom said they had failed the quiz 20 times before passing.
Another said their husband had accompanied them to work on their first day to help translate for them and that they used Google Translate to help them when reading English.
Faton Abrashi, a regional operations manager for Costa Coffee stores in London told the inquest on Thursday that Costa baristas were only permitted to serve customers who had said they had an allergy when ordering, if they had completed specific allergy safety training.
Mr Abrashi confirmed that, as of February 2023, there was no requirement to complete the online modules in the presence of colleagues, and they could be done at home.
He said the online training is only provided in English, with no other language options, and he, as a regional manager, would not be aware how many times a trainee had attempted the quiz before they passed.
The coroner also noted that on the day of her death, "neither Hannah or her mother were carrying an epi-pen that had been prescribed".
A post-mortem examination found Hannah died after suffering a hypersensitive anaphylactic reaction triggered by an ingredient in her hot chocolate that caused an allergic response.
The inquest previously heard there is a factual dispute about the order, and Ms Duyile says she asked for two soya hot chocolates and asked staff to thoroughly clean the equipment.
However, Costa employee Urmi Akter, who served the girl and her mother, said Ms Duyile asked for one regular and one medium hot chocolate as she was giving evidence in the court on Tuesday.
She says the mother asked for her medium drink to be "extra hot" and for her daughter's to be "normal".
Ms Akter said Ms Duyile told her of her daughter's dairy allergies but that she only asked for the jug used to froth milk to be thoroughly washed.
Ms Akter, who had a Bengali translator with her, said she had not heard Ms Duyile say she wanted two soya milk hot chocolates.
Ms Akter said she washed the jug between making the two hot chocolates - both made with cow's milk by colleague Nicoleta Matei - as the mother requested.
Assistant Coroner Dr Shirley Radcliffe, asked: "Have you ever had any difficulty understanding what someone has said from behind the [perspex] screen [of the Costa till]?"
"Not too much, sometimes," Ms Akter replied.
