The family of a woman with an acute dairy allergy who died after eating a Pret a Manger sandwich contaminated with milk have said her death was "entirely avoidable".
Celia Marsh, 42, a dental nurse from Melksham, Wiltshire, died on December 27 2017 after eating a super veg vegan wrap from the sandwich chain's Bath store.
The yoghurt dressing in the wrap was later found to be contaminated with traces of milk protein stemming from a starch manufactured in a facility handling dairy products.
The mother-of-five purchased the wrap at 2.08pm, and within 15 minutes entered acute anaphylactic shock. She was declared dead at 4pm.
Today (Thursday), a coroner at Avon Coroner's Court in Bristol, concluded that the yoghurt manufacturer had documentation warning of the risk of cross-contamination of the starch.
The CoYo branded yoghurt, which is Australian, was licenced for manufacture in the UK to a company called Planet Coconut.
Bags of the HG1 starch, produced by Tate and Lyle PLC, carried the warning "manufactured in a factory that handles milk, eggs, cereals containing gluten, sulphur dioxide and sulphites".
Coroner Maria Voisin said Pret a Manger had not been alerted to the risk, and that the yoghurt was labelled as "dairy free".
Ms Voisin said: "The contamination (of the wrap) arose because an ingredient in the yoghurt called HG1 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."
Speaking outside of the inquest, Marsh's daughter Ashleigh Grice said: "It is now almost five years since our mum Celia was taken from us, she knew she had a serious food allergy – because of that constant fear mum was extremely cautious in all she ate, checking every label, often triple checking, for dairy.
"On that terrible day she trusted the ‘dairy free' labelling in the Pret a Manger store, but the vegan wrap had been contaminated with milk protein.
"The content was poisonous to her and she collapsed in the street."
Grice added: "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.
"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.
"Through the Pret allergy plan, we made a clear commitment to lead the industry in developing new policies for people with food allergies. We will continue to do everything we can to help every customer get the information they need to make the right choice for them."
A spokesman for Planet Coconut said the company had "co-operated fully" with the inquest.
The company believed that the yoghurt was made in a "dairy-free production environment", he added. "Our thoughts remain as ever with the family of Mrs Marsh," the spokesman said.
Mrs 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 bought at Heathrow Airport.
Ednan-Laperouse had a sesame allergy.
The tragedy sparked an overhaul of food labelling laws which now requires retailers 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.
Natasha's mother Tanya Ednan-Laperouse, co-founder of The Natasha Allergy Research Foundation, which has been supporting the Marsh family, said: "The great tragedy of allergy deaths is that they are mostly avoidable. Celia's husband and five daughters have to live with this terrible truth.
"Lessons must be not just learned but actioned."
The Natasha Allergy Research Foundation is calling for anaphylaxis to be made a "notifiable disease" meaning all incidents must be reported to Government authorities in order to monitor it and build high quality data.
Mrs Ednan-Laperouse said: "This would result in instant precautionary product recalls which could save lives, and an accurate picture of the true toll of the numbers of serious incidents and fatalities from food anaphylaxis."
Mrs Marsh's family are also calling for anaphylaxis to be made a notifiable disease.
Image: Shutterstock/Willy Barton