An update on the previous Comms following Inquest of child death from an anaphylactic reaction

Dear Colleagues,

I am re-issuing my email sent on 18 November 2024 due to some content inaccuracy, to ensure that the correct information is on record.

The recent inquest in August 2024 into the tragic death of 13-year-old Hannah Jacobs, who died in February 2023 from an anaphylactic reaction, has highlighted several important learning points.

The Assistant Coroner, who held the inquest, issued several Prevention of Future Death (PFD) notices to multiple agencies. 

There has been one reported issue which needs addressing regarding school policies on adrenaline auto-injectors (often referred to by the brand name Epipen®).

At the time of the Regulation 28: Report to Prevent Future Deaths, the coroner understood that the school Hannah attended did not have a policy of allowing pupils to bring their own adrenaline auto-injectors into school as they held their own stock. The school have since advised that this is incorrect and that the stock held by the school was for emergency use only which was in line with the Clarification of AAI guidance in March 2023.

Having reviewed the detail of the Regulation 28 Report, the comment in my original email that Hannah collapsed after school is inaccurate. We would like to confirm that the report states that Hannah collapsed before attending school.

As we look ahead in particular to Christmas festivities and possible changes in routine which arise from celebration events, we ask all School related health services and all paediatric and paediatric allergy services to reinforce the message that all children and young people who have been prescribed an adrenaline auto-injector are reminded that they should have two unexpired devices with them at all times, including on the way to & from school.   This is in line with previously published guidance https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1148583/AAI_HMR238_Clarification_Dr_P_Turner.pdf, and https://assets.publishing.service.gov.uk/media/5a829e3940f0b6230269bcf4/Adrenaline_auto_injectors_in_schools.pdf.

We would also ask that all School related health services work with their local school to ensure that the school policies do not prevent children and young people from carrying these life-saving auto-injectors to & from school.

Kind regards.

Jennie Hall OBE
Director of Nursing
NHS England (London)