A 13-year-old girl with severe allergies died due to a failure to follow allergies processes and a failure of communication with baristas, a coroner has ruled.

Hannah Jacobs died hours after taking a sip from a Costa hot chocolate that she believed was made with soya milk but was actually made with cow's milk.

Assistant Coroner Dr Shirley Radcliffe revealed she would be writing to several government departments to ensure a 'tragedy' similar to Hannah’s death would never happen again. 

Hannah’s bereaved mother, Abimbola Duyile, told East London Coroner’s Court she had ordered two soya milk hot chocolates from Costa inStation Parade, Barking, and told staff of her daughter’s severe dairy allergies. 

However, the barista taking her order, Urmi Akter, later claimed Ms Duyile had asked for one ‘extra hot’ and one ‘normal’ hot chocolate - not having specified for them to be made with soya milk but merely insisting the milk jug was cleaned between making the drinks. 

Forensic analysis of Hannah and her mother’s coffee cups later found no traces of soya milk but ‘substantial levels’ of milk protein. 

Nicoleta Matei, the barista who made the mother and daughter’s drinks, told the inquest she’d heard Ms Duyile say her daughter had a dairy ‘intolerance’, but did not hear her use the word allergy. 

Giving a short-form narrative conclusion, Dr Radcliffe said: “We heard Hannah was a happy, lively 13-year-old with an outspoken, strong personality. 

“She was diagnosed with severe allergies. She and her mother managed these allergies well. 

“She was prescribed an epi-pen. She had never had the need for an epi-pen. 

“The route cause of this death was a failure to follow the process in place to discuss allergies with customers, combined with a failure in communication between the mother and barista. 

“There was clearly a lack of comprehension. I think it is of note that Ms Akter had an interpreter in court. 

“There was also the fact that Hannah did not have an epi-pen with her.

“Once in the pharmacy, she was in extremis. She needed a [higher dose] of epi-pen that was not available due to a nationwide shortage at the time. 

“The treatment of the ambulance service was prompt and well performed.

“Hannah died at Newham University Hospital on February 8, 2023, following a cardiac arrest after an allergic reaction to dairy. 

“Hannah was served a dairy hot chocolate at Costa Coffee despite her mother warning staff of her dairy allergies.

“Tragically, she was pronounced life extinct on the same day.

"There was clearly a major communication error."

Dr Radcliffe recorded that Hannah died as a result of hypersensitivity anaphylaptic reaction after drinking her Costa hot chocolate - which triggered an acute allergic response. 

However, she found Hannah was not unlawfully killed nor suffered neglect. 

“I don’t think there is sufficient evidence that there was a serious and obvious risk of this death to the baristas in Costa Coffee,” Dr Radcliffe said. 

“I do not think it meets the threshold for unlawful killing on the balance of probabilities.

"There was clearly a major communication failure."

She added that she would be sending Prevention of Future Deaths reports to both the Department of Education (DfE) and the Department of Health and Social Care (DHSC).

Dr Radcliffe said writing to the Department of Education would be her ‘first priority’. 

The inquest heard Hannah’s school had epi-pens but did not allow pupils to bring their own into school - meaning many schoolchildren with allergies are without Adrenaline Auto Injectors (AAIs) while they travel to and from school. 

She said: “The safety of children with allergies travelling to and from schools is]my first priority.”

In a statement after the inquest, Hannah's mother said: "Hannah was just entering adolescence and learning to be independent, taking ownership of her allergies when she was tragically taken from us.

"She had known from a young age what her allergies were and took them very seriously.

"I have always been extremely diligent in managing Hannah’s allergies and she had never suffered a serious allergic reaction prior to this incident."

She described Hannah as a vivacious, caring, affectionate, outspoken child who everything to live for.

She said: "Having heard all the evidence over the last week it is clear to me that although the food service industry and medical professionals are required to have allergy training, this training is really not taken seriously enough. And better awareness is needed in these industries and across society of the symptoms of anaphalxis."

Referring to what is permissible in the two industries, she went on: "Allowing people who serve food and drinks to retake an allergy training test 20 times is not acceptable. Treating allergy training as a tick box exercise is not acceptable.  

"Being a medical professional and not reacting quickly to even a possible anaphylactic reaction is not acceptable. 

"And the consequence is that my daughter is no longer here. My beautiful Hannah only had 13 years on this earth when she should have had many, many more.  

"I truly believe that with Hannah’s combination of confidence, outspokenness, deep sense of right and wrong and her natural thoughtfulness and affectionate nature she could have achieved so much in this world."

Abi said her family and her dearest friend Ripal would like to thank the bystander in the pharmacy who heroically stepped in to help Hannah, the London Ambulance Service for their rapid response, Nadim and Tanya Ednan Laperouse for their emotional support, and coroner Dr Radcliffe for conducting a thorough investigation.