Byron burger chain ‘misled’ tragic 18-year-old into believing there were no allergens, coroner rules

Owen Carey, 18, died in his girlfriend’s arms in front of the London Eye, in 2017

The family of a teenager who suffered a fatal reaction after eating a birthday burger at a Byron restaurant are calling on the Government to improve food labelling – after a coroner ruled staff misled him over ingredients.  

Owen Carey, 18, told staff he was allergic to dairy, but suffered a fatal reaction after eating grilled chicken coated in buttermilk at the restaurant at the O2 Arena in Greenwich in April 2017. 

Now the teenager’s heartbroken family are calling on the Government to improve restaurant food labelling, saying they hope that ‘something good’ could come from their tragic loss. 

The parents of Natasha Ednan-Laperouse, 15, who died after eating an unlabelled sesame seed Pret A Manger baguette, attended the inquest, and called Mr Carey’s case a ‘landmark judgment for millions of allergy sufferers in this country’. 

In a written conclusion, assistant coroner Briony Ballard, sitting at Southwark Coroner’s Court, today ruled: ‘The deceased died from a severe food-induced anaphylactic reaction from food eaten and ordered at a restaurant despite making staff aware of his allergies.’

She added: ‘The menu was reassuring in that it made no reference to any marinade or potential allergenic ingredient in the food selected.

‘The deceased was not informed that there were allergens in the order.’ 

She earlier suggested at the inquest that all restaurant menus should display a red ‘A’ sign next to dishes that contain allergens.

But Aimee Leitner-Hopps, of Byron, said such a system would ‘breed complacency’ as it would appear next to ‘about 95 per cent of dishes’. 

Owen, from Crowborough, East Sussex, died in his girlfriend’s arms on 22 April, 2017. Paramedics had battled to save him after he was helped by passers-by but he died from anaphylactic shock.

The inquest was told he had forgotten his epipen but would not have survived even if he was carrying it.

Speaking outside Southwark Coroner’s Court today, Emma Kocher, Owen’s sister, said the teenager’s death ‘should not be forgotten’, adding: ‘We hope now that something good can come out of it and we are calling on the government to change the law on allergen labelling in restaurants.

‘We want restaurants to have to display clear allergen information on each individual dish on their menus.

‘The food industry should put the safety of their customers first and be proactive in protecting those with allergies.

Owen Carey’s family are pictured outside Southwark Coroner’s Court today after assistant coroner Briony Ballard ruled: ‘The deceased died from a severe food-induced anaphylactic reaction from food eaten and ordered at a restaurant despite making staff aware of his allergies’

Owen’s father Paul is seen crying outside Southwark Coroner’s Court following today’s ruling

The family of Owen Cary, mother Moira (centre) and sister Emma Kocher (right), outside Southwark Coroner's Court following the ruling at his inquest that he was misled into believing that there were no allergens in his meal at the Byron hamburger restaurant

The family of Owen Cary, mother Moira (centre) and sister Emma Kocher (right), outside Southwark Coroner’s Court following the ruling at his inquest that he was misled into believing that there were no allergens in his meal at the Byron hamburger restaurant

‘It is simply not good enough to have a policy which relies on verbal communication between the customer and their server, which often takes place in a busy, noisy restaurant where the turnover of staff is high and many of their customers are very young.

‘This leaves far too much room for error on an issue we know all too well can cost lives.

‘We hope that we can bring about change with Owen’s Law, for better allergen labelling in restaurants.’ 

Coroner Briony Ballard (pictured) said: 'My conclusion is that Owen did explain he had allergies and that he was allergic to dairy and wheat to the member of staff who served his table'

Coroner Briony Ballard (pictured) said: ‘My conclusion is that Owen did explain he had allergies and that he was allergic to dairy and wheat to the member of staff who served his table’

Mr Carey was allergic to wheat and dairy products but there was no mention of buttermilk on the menu at the restaurant at the O2 in North Greenwich, Southwark Coroner’s Court heard.

Delivering her ruling at Southwark Coroner’s Court today, coroner Briony Ballard said: ‘Owen Carey’s death is tragic.

‘He was only just turned 18 and was in fact out for a birthday treat with his girlfriend on the 22 April 2017 when he unknowingly ingested an ingredient, buttermilk, to which he was allergic, suffering a severe anaphylactic collapse and died.

‘My conclusion is that Owen did explain he had allergies and that he was allergic to dairy and wheat to the member of staff who served his table.

‘I conclude it was at that point that the system that the system that Byron had broke down.

‘It would be speculative to conclude why the system broke down.

‘From the point of order I conclude Owen ordered and was served food which unbeknownst to him contained an allergen, dairy.’ 

Speaking outside court, family lawyer Thomas Jervis said there had been a ‘failure’ on the part of the server to act upon Owen’s allergies.

He said: ‘Owen was reassured by the description of the chicken which did not mention any marinade or additional ingredients.

‘The food regulations relating to allergy information are clearly not fit for purpose.

‘It cannot be right that there is such room for human error on an issue that can be fatal.

Speaking outside Southwark Coroner's Court today, Emma Kocher, Owen's sister, said the teenager's death 'should not be forgotten'

Speaking outside Southwark Coroner’s Court today, Emma Kocher, Owen’s sister, said the teenager’s death ‘should not be forgotten’

In a statement outside Southwark Coroner’s Court, Mr Carey’s family said: ‘Owen was the shining light in our family’

‘There are millions of people in the UK who suffer from food allergies, and it is only right that they are able to make fully informed decisions about the food that they eat.’ 

The coroner said that Owen’s medical history included unstable asthma and severe food allergies.

She added that Owen was a ‘confident’ orderer, and perfectly capable of bringing up his allergies to serving staff.

‘The deceased died from severe food induced anaphylaxis, from food ordered at a restaurant despite making food serving staff aware of his allergies,’ said Ms Ballard.

Ms Ballard expressed concern that the death rate from allergies remained ‘static’, despite increased awareness.

The inquest was told Mr Carey had forgotten his epipen but would not have survived even if he was carrying it (pictured: Mother Moira Carey)

Father Paul Carey

The inquest was told Mr Carey had forgotten his epipen but would not have survived even if he was carrying it (pictured left: Mother Moira Carey outside court today. Right: Father Paul Carey)

Nadim and Tanya Ednan-Laperouse, the parents of 15-year-old Natasha Ednan-Laperouse who died after eating a Pret A Manger sandwich, called Mr Carey's inquest a 'landmark judgment for millions of allergy sufferers in this country' (pictured outside court today)

Nadim and Tanya Ednan-Laperouse, the parents of 15-year-old Natasha Ednan-Laperouse who died after eating a Pret A Manger sandwich, called Mr Carey’s inquest a ‘landmark judgment for millions of allergy sufferers in this country’ (pictured outside court today)

Owen Carey’s mother Moira Carey paid tribute to her son after the inquest.

She said: ‘Owen had a load of energy and was always smiling, and wanted to get to the most out of life.’

Owen played trumpet, violin and electric guitar, and there was ‘always noise in the house’, she said, adding: ‘It was great.’

Mrs Carey said there are ‘hundreds of thousands’ of allergy sufferers who are scared to eat out in restaurants because ‘that is the key place where they are at risk’.

Owen’s father Paul Carey said he would ‘always think of the times’ he had together with his son.

He added: ‘He was an excellent chap, a beautiful boy and a great mate.’

In a statement, Nadim and Tanya Ednan-Laperouse, the parents of 15-year-old Natasha who died after eating an unlabelled sesame seed Pret A Manger baguette, said: ‘We have heard remarkable parallels between Owen and Natasha’s death.

‘Owen’s death yet again highlights the inadequacy of food information in this country.

‘NATASHA’S LAW’

Natasha Ednan-Laperouse, who died after she fell ill on a flight from London to Nice after eating a Pret A Manger sandwich

Natasha Ednan-Laperouse, who died after she fell ill on a flight from London to Nice after eating a Pret A Manger sandwich

 In June 2019 the Government announced it would introduce ‘Natasha’s Law’, which requires food businesses to influde full ingredients labelling on pre-packaged foods.

The law gets its name from Natasha Ednan-Laperouse, the teenager who died after suffering an allergic reaction to a Pret a Manger baguette.

Then-Environment Secretary Michael Gove confirmed legislation would be brought forward by the end of summer to strengthen allergen labelling rules.

The legislation, known aims to tighten the rules by requiring foods that are pre-packed directly for sale to carry a full list of ingredients – giving allergy sufferers greater trust in the food they buy.

The reforms cover labelling requirements for foods that are prepared and packed on the same premises from which they are sold – such as a packaged sandwich or salad made by staff earlier in the day and placed on a shelf for purchase. 

‘This verdict is a landmark judgment for millions of allergy sufferers in this country and another clear statement to the food industry that things cannot go on as they are.

‘Our hearts go out to Owen Carey’s family, who will always carry their terrible grief knowing Owen’s death was so preventable.’

In June this year former Environment Secretary Michael Gove promised a new law protecting allergy sufferers following Natasha’s death.

Under ‘Natasha’s law’, food businesses will have to include full ingredients labelling on pre-packaged food, with the law scheduled to take effect from October 2021.

Mr and Mrs Ednan-Laperouse added: ‘With around 8% of children in this country now having allergies, we are facing an epidemic.

‘The food industry should be leading the charge for better information for its millions of customers with allergies, not hiding – as has Byron Burgers – behind corporate legal-speak of being ”industry standard” or ”meeting our legal obligation”.

‘Customers with allergies… deserve so much better.

‘It is obvious the Food Information Regulations 2014 are out-of-date.

‘While we wait for the coroner’s final prevention of deaths report, and the necessary law change, we are calling on the restaurants to implement full allergen menus before other lives are needlessly lost.

‘Finally we strongly welcome the coroner’s call for a national register of deaths by anaphylaxis so that all the relevant authorities are fully aware of the full number of fatal incidents which we currently believe are under-reported’.

Aimee Leitner Hopps, in charge of health and safety compliance at Byron, told the inquest that the allergy information on the menu met industry standards at the time.

The menu used by Byron in April 2017 was a two-sided place mat menu which asked customers to inform staff of allergies at the back.

‘Our legal obligation is to demonstrate the information can be provided,’ Ms Hopps said.

‘So we have a signpost that asks if you have any allergies,’ she said.

‘Certainly we have never been notified of any issues with the location or the size of the text.

‘It is very much what the industry standard is.’

Mr Carey was allergic to wheat and dairy products but there was no mention of buttermilk on the menu at the restaurant at the O2 in North Greenwich, Southwark Coroner’s Court heard

Mr Carey died in April, 2017

Mr Carey (pictured) was allergic to wheat and dairy products but there was no mention of buttermilk on the menu at the restaurant at the O2 in North Greenwich, Southwark Coroner’s Court heard

The inquest heard that dishes on the menu indicated if they contained one of the 14 common allergens.

‘Most business would take the approach that the customer would notify the restaurant if they had an allergy,’ said Ms Leitner-Hopps.

Briony Ballard asked her ‘In effect you are trying to put the responsibility on the customer, aren’t you?’

Ms Leitner-Hopps replied: ‘It is not about shifting responsibility, it is about the expectation that when a customer has an allergy they would tell us.’

Byron staff go through online training which also covers allergies, which consists of them ticking a box indicating they have read the section.

The schoolboy was popular pupil and was a prefect at Skinner’s School in Tunbridge Wells.

The schoolboy (pictured) was popular pupil and was a prefect at Skinner’s School in Tunbridge Wells

Ms Leitner-Hopps said waiters also had a week’s restaurant training where allergens were covered.

Byron’s policy has now changed and servers ask customers if they have any allergies.

The kitchen is then notified so that proper sterilisation and procedures to avoid cross-contamination were put in place.

Food outlets have faced mounting scrutiny of their food allergy policies following an inquest last year into the death of Natasha Ednan-Laperouse, 15, who died of an allergic reaction after eating sesame seeds contianed in a Pret a Manger baguette.

Natasha’s parents, Nadim and Tanya, are supporting Owen’s family.

Paediatrician calls for national register into food allergy deaths 

A leading paediatrician called for a national register of food allergy deaths after an 18-year-old lad suffered a fatal reaction to eating a Byron chicken burger.

Giving evidence at an inquest into the death of Owen Carey, Dr Robert Boyle told Southwark Coroner’s Court: ‘I do think there’s a real failure to learn from the tragic occurrence.

‘I think a lot of knowledge comes to the fore in court, detailed information around the pathology, the circumstances surrounding the event – that’s as far as it goes.

‘We probably had 150 deaths like this in the UK over the last 15 years. I just don’t think we are learning enough as it is.’

Calling for a national register for food allergy deaths, he added: ‘It would be just to understand what are the risks that lead to fatal food anaphylaxis.

‘I think the Food Standards Agency have a sort of regulatory governmental role and are quite interested in food allergies.

‘I think they would need to be involved and the Anaphylactic Campaign; they would love to be involved.’

He said The British Society for Allergy and Clinical Immunology should also be consulted.

Dr Boyle said: ‘I think your own community, the coroner’s, somehow need to engage with that.

‘Food allergy is a big deal really for the food industry, for education, health, for families. This is quite an important part of the picture for this very unpredictable and very awful thing happening, we do need to learn a little bit more about it.’

He disagreed with the medical cause of death given by Professor Lack, adding: ‘I would call this fatal food anaphylaxis, but it’s debatable.’

Owen’s cause of death was originally determined by Professor Gideon Lack, an expert in paediatric allergy at Kings College London.

Figures show that one in 12 children and one in ten adults are allergic to at least one food. 

The inquest heard that Owen had ordered the skinny version of the classic chicken, which did not include the bun containing gluten.

But the menu made no mention of the fact the chicken fillet was marinated in buttermilk prior to being grilled, which Owen was allergic to.

Clodagh Bradley QC, representing Mr Carey’s family, pointed out to Ms Leitner-Hopps that the allergy notice on the Byron’s children’s menu was more prominent and at the front.

‘We do not have any such notice at all on the front of the menu that sets out all the food options available in April 2017,’ said Ms Bradley.

Ms Leitner-Hopps said: ‘It is not the reverse, this menu is intended to be two-sided information.’

‘This side sets out all the food options available on April 2017.

‘On the reverse is effectively a special feature about the new burger, a Kimchi burger,’ said Ms Bradley.

The barrister added: ‘You would agree if a customer is not interested in the Kimchi burger and glanced at that side, they would not read further because they would think it relates to the burger.’

But Ms Leitner-Hopps insisted that a customer with allergies is likely to be looking for that information.

Ms Bradley highlighted that the burger Owen ordered was described as grilled on the menu, with no mention of a marinade.

‘Would you accept that the description grilled chicken breast would lead the reader to believe it is a plain chicken breast,’ said Ms Bradley.

‘I believe that would be making a an assumption that is not quite valid,’ Ms Leitner-Hopps said.

‘We do not list all the ingredients in the menu, it is simplified. You do not say there is mayonnaise in coleslaw.’

Ms Leitner-Hopps denied the description was misleading, saying nobody had complained about that since the item was introduced in 2013.

Ms Bradley showed the court a picture taken of a Byron menu by Owen’s family in April last year, which showed the menu list buttermilk as an ingredient in the chicken.

Ms Leitner-Hopps said the change was made simply because buttermilk had since become a fashionable ingredient.

She insisted that listing all allergens in the menu would in fact make customers less safe, as it might lead them not to ‘assumptions’ and not disclosing their allergies.

Byron’s policy has now changed and servers ask customers if they have any allergies (stock photo)

Byron’s policy has now changed and servers ask customers if they have any allergies (stock photo)

‘We have procedures and our kitchen team have the chance to reduce cross-contamination,’ she said.

‘The benefit is having that discussion and making sure everyone is aware the customer has an allergy.’

Lucy Urquhart, from Trading Standards at the Royal Borough of Greenwich, told the court they concluded that something went wrong when staff took Owen’s order.

‘The whole matter revolves around the conversation that happened or didn’t happen at the table at the time of order,’ said Ms Urquhart.

‘For whatever reason Byron’s allergy policies were not triggered.’

Owen was due to visit the Sea Life Aquarium after visiting the Star Wars exhibition at the 02 Arena as a surprise gift earlier in the day

Owen was due to visit the Sea Life Aquarium after visiting the Star Wars exhibition at the 02 Arena as a surprise gift earlier in the day

Owen was due to visit the Sea Life Aquarium after visiting the Star Wars exhibition at the 02 Arena as a surprise gift earlier in the day.

The schoolboy was popular pupil and was a prefect at Skinner’s School in Tunbridge Wells.

He usually carried an EpiPen but forgot to on the day of his death and had never suffered an allergic reaction before.

A post mortem revealed the cause of death was ‘asthma exacerbation in the context of a severe food allergic reaction’ – common in people who suffer a fatal anaphylactic shock, Southwark Coroner’s Court heard.

Dr Robert John Boyle, a consultant paediatric analyst at St Mary’s Hospital, told the hearing: ‘There are very few things so powerful that they can take away a young life that quickly.

‘We cannot be completely certain whether or not an epipen would have made a difference.

‘I think, personally, that it would have been unlikely that an epipen would have made a difference. It sounds like he was extremely difficult to resuscitate.’

Earlier Southwark Assistant Coroner Briony Ballard, reading paramedic Anneliese Tien-Yin Wong ‘s statement, said security staff had lowered the bollards at the London Eye to give the ambulance access to the pedestrian area.

The paramedic said: ‘The patient was located on the pavement in a pedestrian area in front of the London Eye.

‘There were three bystanders who identified themselves as doctors on scene.

‘The patient was unresponsive, silent and not breathing and pulseless.’

The doctors continued to perform CPR and paramedics extracted 1.5 litres of vomit from Owen’s airways with a suction device, the inquest heard.

Owen’s girlfriend told them he had suffered an allergic reaction, and didn’t have his epipen.

The medics administered five shots of adrenaline and one of hydrocortisol for anaphylactic shock.

Ms Wong said there was a delay to administering the drugs due to ‘managing the chaotic nature of the crowds and bystanders around us’ before Owen was rushed to nearby St Thomas’s Hospital.

Owen was rushed into A&E, but was pronounced dead shortly after arrival.

Dr Pippa Alamango, the hospital registrar who treated him in A&E, said ‘Owen’s allergic symptoms started after he ate half of his chicken burger because, according to his girlfriend, he shortly after developed symptoms of lips tingling and abdominal pain.

‘He then required his asthma inhaler.

‘His symptoms started at approximately 2.45pm and he collapsed at approximately 3.45pm.’

The inquest heard Owen had been going to hospital twice a year due to his asthma and suffered various other allergies.

Reading a post mortem report, the Assistant Coroner said the medical cause of death was found to be ‘asthma exacerbation in the context of a severe food allergic reaction.’

She added: ‘It’s estimated that half a chicken burger containing 5g of buttermilk.

‘Although this is a small amount of cow’s milk protein, it would be sufficient to cause anaphylactic reaction in a person with an allergy.

‘In the case of Owen, there was milk ingest at a dose that clearly caused an allergic reaction.

‘Having food allergies increases the risk of spontaneous fatal or life threatening asthma.

‘Owen had numerous respiratory allergies including cat, house dust mite, tree and pollen. The day of his death in Spring had high pollen.’

She added: ‘In summary the likelihood of milk allergies triggering this event is high, but the possibility of spontaneous asthma cannot be discounted.’   

Byron chief executive Simon Wilkinson said in a statement: ‘We take allergies extremely seriously and have robust procedures in place and although those procedures were in line with all the rules and guidelines, we train our staff to respond in the right way.

‘It is a matter of great regret and sadness that our high standards of communicating with our customers were not met during Owen’s visit.

‘We believe we always did our best to meet our responsibilities but we know that this will be of no comfort to Owen’s family.

‘We have heard what the coroner said about the need to communicate about allergies and it is clear that the current rules and requirements are not enough and the industry needs to do more.

‘We will make it our priority to work with our colleagues across the restaurant industry to ensure that standards and levels of awareness are improved.’

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