The death of a 13-year-old girl after taking a sip of Costa Coffee hot chocolate was due to “failure to follow existing procedures for discussing allergies,” a coroner ruled.

There had been a “communication breakdown” between staff at the Costa in Barking, east London, and the girl’s mother, the East London Coroners’ Court was told on Friday.

Hannah Jacobs, who suffered from a severe allergy to dairy, fish and eggs since childhood, died on February 8, 2022, a few hours after taking a sip of the drink containing cow’s milk.

Deputy Coroner Dr Shirley Radcliffe said: “The actual cause of death is failure to follow established procedures for discussing allergies and a lack of communication between the mother and the barista.”

The coroner also noted that on the day of her death, “neither Hannah nor her mother carried a prescribed EpiPen” in case she was exposed to an allergen.

An autopsy revealed that Hannah died of an anaphylactic hypersensitivity reaction triggered by an ingredient in her hot chocolate that caused an allergic reaction.

In a statement after the inquest, Hannah’s mother Abimbola Duyile said she had been “extremely diligent” in managing her allergies and that her daughter had taken them “very seriously”.

She described her as “lively, caring, loving, energetic and outspoken… with a strong sense of right and wrong.”

“My beautiful Hannah only had 13 years on this earth when she should have had many, many more,” she said.

Read more: Allergy sufferers report “traumatic” experiences when ordering food

Ms Duyile said allergy education was “not taken seriously enough” and that it was unacceptable to treat it as a mere “box-ticking exercise”.

The investigation found that at the time of Hannah’s death, training on allergens for new Costa employees consisted of a series of online modules that could be accessed remotely and repeated until answers were correct.

Costa Coffee said in a statement: “The loss of Hannah is a tragedy and our sincere thoughts go out to her family and friends.

“It is in everyone’s interest to understand how this terrible situation came about. We have listened to everything the coroner has said this week and will carefully consider her comments and any report she may issue and respond accordingly.”

Went to the pharmacy instead of taking EpiPen

The investigation revealed that the teenager had a “immediate reaction” to the drink, even though her mother had ordered two hot chocolates with soy milk.

Ms Duyile told the hearing that as soon as Hannah drank the hot chocolate she complained of chest pains and that her lips and mouth were very swollen and itchy.

Urmi Akter, who served Hannah’s mother, testified in court that she asked the question: “Can you wash the jug because my daughter is allergic to milk?”

In accordance with Costa’s allergen rules, Ms Duyile was not given a book with nutritional recommendations, the court heard.

In her statement, Ms Akter said she did not show the book to Ms Duyile “because she told me that washing the jug was not a problem”.

Read more from Sky News
Student missing for a week
“No hate crimes” at comedy show in Edinburgh
Victims of abuse in nursing homes speak out

Hannah tried the drink on the way to the dentist and felt unwell, so nurses offered Ms Duyile an EpiPen containing 300mg of adrenaline, dentist Iqra Farhad told the court.

Ms Farhad said this could have saved Hannah’s life, but Ms Duyile instead decided to go to the pharmacy and get an antihistamine called cetirizine.

She told the court she had only seen Hannah briefly and said there were “no signs of panic or distress”.

However, when they arrived at the pharmacy, EpiPens were out of stock due to general shortages, pharmacist Santokh Kahlon said in his testimony.

He said in court that he would have “definitely” used the extra EpiPen from the dentist if he had known one was there.

Zeenat Panirwala, a customer of the pharmacy at the time, added that Ms Duyile found it “difficult” to process what had happened when she saw Hannah in distress.

She said she heard Ms Duyile blaming Costa for giving her child the drink and was “hysterical, saying, ‘She’s dead, she’s dead'”.

“Urgent” government action required

Nadim and Tanya Ednan-Laperouse, whose 15-year-old daughter Natasha died after eating a baguette from Pret A Manger which contained sesame seeds, participated in Hannah’s examination and supported her family.

A subsequent statement said there was an “urgent” need for government action to help “schools, businesses and society” better understand that “food allergies can be a serious and unpredictable health condition – not a lifestyle issue.”

“Together with Hannah’s grieving mother Abi, and on behalf of other parents who have lost their children to food allergies, we are today again calling on the Government to appoint an Allergy Tsar – a national advocate for the one in three people living with not just food allergies, but all types of allergic conditions, including asthma and eczema,” they said.

“How many more children have to die before we start taking food allergies seriously?”

After Natasha’s death in July 2016 The law has been changed to require all grocery stores to provide a full ingredient list and allergy labelling on foods prepackaged for direct sale.