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Prevention of Future Deaths Report – Adrenaline Auto-Injectors

A recent post noted that HM Assistant Coroner for West London intended to issue a Regulation 28 Prevention of Future Deaths Report to the MHRA raising concerns about the adrenaline auto-injectors used by Natasha Ednan-Laperouse – in particular whether the length of the needle and the dose administered were appropriate.

The Coroner’s report has new been posted on the Judiciary UK website.

The Coroner raises four matters of concern, including two requiring a response from the MHRA with details of action taken or proposed (by 3/12/18):

  • In the Emergency treatment of anaphylactic reactions Guidelines for healthcare providers the preferred needle length is 25 mm for adrenaline injectors to access muscle in most people. I heard during expert evidence that Epipen needle length was 16mm – suitable according to the UK Resuscitation Council for “pre-term or very small infants”. The use of needles which access only subcutaneous tissue and not muscle is in my view inherently unsafe. An alternative autoinjector, Emerade has a 24 mm needle.
  • The dose of adrenaline in Epipen is 300mcg. The UK Resuscitation Council recommends a standard emergency dose of 500mcg. Emerade contains a dose including 500mcg. The combination of what my expert told me was an inadequate dose of adrenaline for anaphylaxis and an inadequate length needle raises serious safety concerns.