A child who died after an anaphylactic reaction to a dairy hot chocolate was given the wrong dose of adrenaline due to a national shortage of Epi-pens, a coroner has found.

Dr Shirley Radcliffe, assistant coroner for East London, called for NHS England, the General Pharmaceutical Council (GPhC) and other bodies to take action to prevent further deaths.

Hannah Jacobs and her mother were incorrectly served dairy hot chocolates at a Costa Coffee franchise in East London on 8 February 2023.

After beginning to suffer signs of an allergic reaction, 13-year-old Hannah and her mother went to a local pharmacy for treatment, the coroner's report recorded.

Thinking that Hannah was suffering a mild to moderate allergic reaction due to swollen lips, her mother asked the pharmacist for cetirizine, before asking for an Epi-pen.

The coroner noted: 'Due to a national shortage there was only one [adrenaline auto-injector] in stock, a 150 micrograms rather than the 500 Hannah had be prescribed. This was given but sadly Hannah went in to cardiac arrest and could not be resuscitated.'

Although she was taken to hospital, she was pronounced dead the same day.

Neither Hannah nor her mother were carrying an Epi-pen, although she kept two at home and two at school, and had been told that she could not carry her prescribed Epi-pen into school.

The coroner said that there had been a vial of adrenaline available at the chemist, but noted: 'it takes time to draw up'.

'I am not sure if (assuming no national shortage) all chemists have AAI [adrenaline auto injectors] in stock for emergencies,' she added.

NHSE and the GPhC must provide a response to the coroner's report by 15 October, outlining any action taken or proposed, or an explanation of why no action is proposed.

The Medicines and Healthcare products Regulatory Agency (MHRA) recommends that patients with serious allergies carry two adrenaline auto-injectors.