A mother-of-five with an acute dairy allergy died after eating a Pret a Manger vegan wrap contaminated with traces of milk, a coroner has found.
Celia Marsh, 42, a dental nurse from Melksham, Wiltshire, suffered anaphylaxis shortly after eating a super-veg rainbow flatbread from the chain’s store in Bath on 27 December 2017.
The coconut yoghurt used as dressing from the Australian brand CoYo, which was licensed for manufacture in the UK to British firm Planet Coconut, had traces of milk protein in it, senior coroner Maria Voisin concluded.
Ms Voisin reached a narrative conclusion on Thursday following a two-week inquest into Ms Marsh’s death at Avon Coroner’s Court in Bristol.
She said the manufacturer of the yoghurt, labelled 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 consumption of a wrap contaminated with milk protein.
“She was not aware that the wrap contained milk protein. The wrap contained a product which was labelled as dairy-free yoghurt alternative but, despite this, contained milk protein which was the cause of Celia‘s anaphylaxis.
“The contamination arose because an ingredient in the yoghurt called HG1 (a starch) had been cross-contaminated with milk protein during its manufacture.
“The manufacturer of the dairy-free yoghurt had in its possession documentation that flagged this risk but this risk was not passed on to its customers.”
The inquest previously heard the mother-of-five avoided all dairy products following a near-fatal allergic reaction a few months earlier in which she needed 15 shots of adrenalin.
Ms Marsh had been on a post-Christmas shopping trip with her husband and three of her daughters when she went into Pret to buy something to eat at about 2pm.
She was declared dead less than two hours later.
The wrap had been consumed in its entirety, and the pot of CoYo brand 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 quantities of dairy protein in the product, with traces found in another rainbow wrap.
During the two-week inquest, a chemist acknowledged the quantity of dairy in the wrap was too low to be measured with any degree of accuracy, but said he believed it definitely contained milk.
It is thought the contamination stemmed from the HG1 starch in the yoghurt.
Speaking after the conclusion of the inquest into the death of her mother, Ashleigh Grice criticised the food industry for its reliance on “vague” food labelling regarding allergens, instead of implementing a strict testing regime.
Ms Grice also criticised the manufacturer of the vegan yoghurt that was contaminated with traces of milk for failing to make Pret a Manger aware of the risk to allergen sufferers.
“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 entirely avoidable.”
Pret a Manger chief executive 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 sympathies remain with everyone who knew and loved Celia.
“We fully support the coroner’s findings. As the coroner made clear, Planet Coconut had information which should have alerted them that their Coyo yoghurt 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 yoghurt may have contained milk, we would have never used the ingredient.
“On Pret’s part, we have taken significant steps forward with our suppliers and labelling policies since 2017.”
Ms 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.
Ms Ednan-Laperouse had a sesame allergy.
The tragedy sparked an overhaul of food labelling laws.
Retailers are now required 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.
Additional reporting by Press Association