A coroner has branded Pret A Manger's allergy labelling "inadequate" following the death of 15-year-old Natasha Ednan-Laperouse, who collapsed while on a British Airways flight shortly after eating a baguette purchased at the chain.
The teenager had suffered an allergic reaction to sesame baked into the baguette, the presence of which was not highlighted on the packaging or on the fridge of the Heathrow Airport outlet in 2016, an inquest into her death heard.
The coroner, Dr Sean Cummings, had expressed concern over rules that mean individual food items prepared in-store are not required to carry allergen warnings, with advice instead permitted to be conveyed via general notices around the shop and vocally by staff.
Delivering his verdict at West London Coroner's Court, Dr Cummings said he would write to Michael Gove, the secretary of state for environment, food and rural affairs, to express concern about large businesses being able to benefit from the legislation.
The coroner had said allergen information relating to the baguette was "inadequate in terms of visibility" and "difficult to see". He added that the lack of specific information on the baguette's packaging had reassured the teenager.
In the year before her death, nine other people had serious allergic reactions related to Pret A Manger products, the inquest heard.
Earlier in the week a food safety officer said that Pret A Manger had conformed with current legislation; however, the coroner referred to the company's process of receiving and monitoring reports of problems relating to allergens as "inconsistent and incoherent"
Pret a Manger chief executive Clive Schlee said: "We are deeply sorry for Natasha's death. We cannot begin to comprehend the pain her family have gone through and the grief they continue to feel.
"We have heard everything the coroner and Natasha's family have said this week. And we will learn from this.
"All of us at Pret want to see meaningful change come from this tragedy. We will make sure that it does."
Speaking outside the court Natasha's father Nadim Ednan-Laperouse said: "Our beloved daughter died of a tragedy that should never have happened.
"We believe that this inquest has shown that she died of inadequate food labeling laws. We are also shocked to learn that there have been a number of previous serious allergy incidents involving sesame seeds at Pret A Manger before our daughter died.
"It feels to us that if Pret A Manger were following the law then the law was playing Russian roulette with our daughter's life. It is clear that food labelling laws, as they stand today, are not fit for purpose and its now time to change the law.
"Natasha's inquest should serve as a watershed moment to make meaningful change and save lives. Thank you."