Comms following Inquest of child death from an anaphylactic reaction

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®)

The school Hannah attended had a policy of not allowing pupils to bring their own adrenaline auto-injectors into school as they held their own stock. The unintentional consequence of this policy was that Hannah was not carrying her auto-injector with her (after she left school) when she had her fatal anaphylactic reaction.

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.