A mother-of-five with an acute milk allergy died after eating a Pret a Manger vegan wrap contaminated with traces of milk, a coroner has found.
Celia Marsh, 42, a dental hygienist from Melksham, Wiltshire, suffered anaphylaxis shortly after eating a super-weighed rainbow flatbread from the chain’s store in Bath on December 27, 2017.
The coconut yoghurt used as a dressing from the Australian brand CoYo, which was licensed for production in the UK to British firm Planet Coconut, had traces of milk protein in it, concluded senior coroner Maria Voisin.
Voisin reached a narrative conclusion on Thursday after a two-week inquest into Marsh’s death at Avon Coroner’s Court in Bristol.
She said the manufacturer of the yogurt, labeled as dairy-free, had documentation that flagged the risk of cross-contamination, but did not pass the information on to customers.
The coroner said: “Celia Marsh was allergic to milk. She died when she suffered anaphylaxis caused by consuming a wrap contaminated with milk protein.
“She was not aware that the wrapper contained milk protein. The package contained a product labeled as a dairy-free yogurt alternative, but despite this contained milk protein which was the cause of Celia’s anaphylaxis.
“The contamination occurred because an ingredient in the yogurt called HG1 (a starch) had been cross-contaminated with milk protein during production.
“The manufacturer of the dairy-free yogurt had documentation that flagged this risk, but this risk was not passed on to customers.”
The inquest previously heard that the mother-of-five avoided all dairy products after a near-fatal allergic reaction a few months earlier in which she needed 15 adrenaline injections.
Marsh had been on a post-Christmas shopping spree with her husband and three of her daughters when she went into Pret to buy something to eat at around 2pm.
She was pronounced dead less than two hours later.
The packaging had been consumed in its entirety and the pot of CoYo yoghurt used to make it was thrown away before Bath and North East Somerset Council began its investigation.
But testing on other pots found small amounts of dairy protein in the product, with traces found in another rainbow foil.
During the two-week investigation, a chemist acknowledged that the amount of dairy in the packaging was too low to be measured with any degree of accuracy, but said he believed it definitely contained milk.
It is believed that the contamination originated from the HG1 starch in the yoghurt.
Following the conclusion of the inquest into her mother’s death, Ashleigh Grice criticized the food industry for its reliance on “vague” food labeling regarding allergens, rather than implementing a rigorous testing regime.
Grice also criticized the manufacturer of the vegan yoghurt which was contaminated with traces of milk for not alerting Pret a Manger to the risk of allergens.
“It is now clear to us that if Planet Coconut had passed on the warnings in their possession to Pret a Manger about the risk of cross-contamination mum would still be alive today,” she said.
“Mum’s death, like so many other allergy deaths, was completely avoidable.”
Pret a Manger boss Pano Christou said: “As a father and husband I can only imagine how distressing this has been for Celia’s children and family. Our deepest sympathy remains with 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 may have contained milk, and this information was not passed on to Pret.
“It goes without saying that if Pret had ever known that the Coyo yogurt might have contained milk, we would never have used the ingredient.
“From Pret’s side, we have taken significant steps forward with our suppliers and brand policy since 2017.”
Marsh’s death came in the wake of 15-year-old Natasha Ednan-Laperouse, who died in 2016 after eating a Pret baguette containing sesame seeds.
Ednan-Laperouse had a sesame allergy.
The tragedy sparked an overhaul of food labeling laws.
Retailers are now required to display full ingredient and allergen labeling on every food item made on site and prepackaged for direct sale, including sandwiches, cakes and salads.
Additional reporting from the Press Association