A woman with a severe allergy to cow’s milk suffered a fatal anaphylactic reaction after eating a “vegan” Pret a Manger wrap contaminated with milk protein, a coroner has concluded.
Maria Voisin, the senior coroner for Avon, said the wrap contained a coconut milk yoghurt supplied by another company, Planet Coconut, that was marked as dairy-free but was found to contain traces of milk protein.
Celia Marsh, 42, a dental nurse from Melksham, Wiltshire, died after eating the “super-veg rainbow flatbread” from the chain’s store in Bath, Somerset.
The coroner said she would write to the Food Standards Agency flagging up concerns about the labelling on products claiming to be dairy-free.
Voisin said Marsh had a “known allergy” to milk. “On that day while in Bath she ate a super-veg rainbow flatbread, which she believed was safe to eat. She suffered an anaphylaxis reaction caused by milk protein, which was in an ingredient. This caused her to collapse and she died.”
Giving a narrative conclusion, Voisin continued: “The wrap contained a product which was marked as ‘dairy-free coconut yoghurt alternative’ but despite this it contained milk protein, which was the cause of Celia’s anaphylaxis.
“A product which is marked dairy-free should be free from dairy. The contamination arose because an ingredient in the yoghurt called HG1 had become cross-contaminated with milk protein during its manufacture.
“The manufacturer of the dairy free yoghurt [Planet Coconut] had in its possession documents which flagged this risk but this risk was not passed on to its customers.”
Marsh’s husband, Andy, 51, had told the inquest in Bristol that his wife was very diligent. “Celia closely monitored her food allergies. She always checked every label before eating and always asked about ingredients. If Celia was not sure about the label or the answers given to her, she would not eat the food as she did not want to take any risks.”
He said his wife had a frightening reaction to dairy in May 2017 while at the dental surgery where she worked after eating something containing marshmallow that had been made on the same line as a product containing milk. She needed 12 shots of adrenalin at the surgery and three in hospital and afterwards always carried an EpiPen.
On 27 December 2017, the Marshes went on a shopping trip to Bath. At about 2pm, Celia Marsh bought a “super-veg rainbow flatbread” from a Pret store.
As they walked down a side street, Marsh was struggling to breathe. She administered her EpiPen and her husband phoned 999. She collapsed and was taken to hospital by ambulance but was pronounced dead at 4pm.
The inquest heard that the wrap contained yoghurt made with coconut milk supplied to Pret by a company called Planet Coconut. An ingredient in the yoghurt – a stabiliser – made by another company was found to have traces of dairy protein.
Speaking after the coroner’s conclusion, Andy Marsh said: “Celia meant the world to us all. She could brighten up your worst days with just one smile. She would look at you with her blue eyes and you just felt better. She was a great mum.”
He added: “I want to see testing at every stage of the process to make sure nothing gets through the cracks and to provide a safety net.”
The couple’s eldest daughter, Ashleigh Grice, 27, who like her mother works as a dental nurse, recalled that Celia Marsh told her she loved her in the last conversation they had.
She said: “Mum and us girls all had Christmas Day together. We were so close. When I left, Mum told me she loved me. I told her: ‘I love you too.’ They were the last words we said to each other.”
Celia’s daughter, Kayleigh Grice, 20, said she was also shopping in Bath on the day her mother died and wished she could have “one more hug or one more conversation”.
She said: “The day that everything happened, we split to go for separate lunches. I do often think that if we had maybe gone with her, then maybe she wouldn’t have eaten the sandwich and she would still be there now.
“Labelling has to be better for people with allergies. There has to be clearer messages. Mum was so on it with labelling, she would triple-check everything. If there was any hint that something may contain something she was allergic to, she wouldn’t touch it or even go anywhere near it.”
Pano Christou, CEO of Pret A Manger, 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 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 yoghurt may have contained milk, we would have never used the ingredient.
“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.”