Coroner rules human error partly to blame in death of teenager with severe allergy
A teenager with a severe nut allergy died after a combination of human and system error, a coroner has ruled.
Shante Turay-Thomas (pictured) died after waiting for an ambulance to arrive at her family home in Wood Green, north London, in September 2018, after eating a hazelnut.
The inquest into her death heard how call staff with the NHS’s 111 non-emergency number failed to appreciate how Ms Turay-Thomas’s worsening condition was typical of suffering a severe allergic reaction to nuts.
A telephone recording of the 111 call, made by Ms Turay-Thomas’s mother, Emma Turay, at 11.01pm on Friday September 14, revealed how the 18-year-old could be heard in the background struggling for breath.
She said: “My chest hurts, my throat is closing and I feel like I’m going to pass out.”
Ms Turay-Thomas then asked her mother to check how long the ambulance would be, before adding: “I’m going to die.”
It is believed the teenager had eaten food containing hazelnuts, a product she had declined to be tested for as a child.
The inquest heard Ms Turay-Thomas tried to use her auto-injector adrenaline pen, but said it did not work, and her condition worsened.
It later emerged she had not received medical training after moving from the EpiPen to a new Emerade device, and had not been prescribed a larger dose.
She was also unaware of the need to use two shots for the most serious allergic reactions.
It meant Ms Turay-Thomas only received a 300 microgram dose, rather than the 1,000 microgram dose needed to help combat severe anaphylactic shock.
The inquest also heard how an ambulance was originally dispatched to the patient, but was re-routed because the call was wrongly categorised as requiring only a category two response, rather than the more serious category one.
An ambulance eventually arrived more than 40 minutes after Ms Turay first contacted the 111 service. She died later in hospital, with a post-mortem examination identifying acute anaphylaxis as the cause of death.
Recording a narrative verdict at St Pancras Coroner’s Court, coroner Mary Hassell said: “Shante suffered a cardiac arrest. An ambulance arrived six minutes later – too late for her.”
The coroner said that Ms Turay-Thomas would have survived had she been given “appropriately robust training” about treating her condition, administered the correct dose, the 111 call handler responded correctly to her condition, and if NHS Digital had categorised anaphylaxis as requiring a category one response.
Ms Hassell said: “Then 111 would have sought a category one ambulance and Shante would have been advised to administer her first pen at least by 11.08pm, she would have been advised to administer the second (pen) five minutes later, the ambulance would have reached Shante by 11.15pm, by which time she would have had a total of 1,000 micrograms of adrenaline, and she would still have been retrievable.
“If paramedics had then treated her appropriately, Shante Turay-Thomas would not have died from acute anaphylaxis.”
Ms Turay broke down and left the court room as details of her daughter’s death were revisited on Monday.
The coroner said she intended to make a prevention of future deaths report.
She added: “It only remains for me to say I’m so very, very sorry for the loss of such a young girl.”
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