A teenager with a severe nut allergy died following a combination of human and system error, a coroner has ruled.
Shante Turay-Thomas died after she had a severe reaction to eating a hazelnut.
The inquest heard a series of failures meant that an ambulance took more than 40 minutes to arrive at her home in Wood Green, north London.
Call staff for the NHS’s 111 non-emergency number failed to appreciate how her worsening condition was typical of a severe allergic reaction to nuts.
A telephone recording of the 111 call, made by Ms Turay-Thomas’s mother, Emma Turay, at 23:01 BST on Friday 14 September, 2018, revealed how the 18-year-old could be heard in the background struggling to breathe.
“My chest hurts, my throat is closing and I feel like I’m going to pass out,” she said before asking her mother to check how long the ambulance would be, before adding: “I’m going to die.”
The inquest heard Ms Turay-Thomas had tried to use her auto-injector adrenaline pen, however it later emerged she had only injected a 300 microgram dose, rather than a 1,000 microgram dose that was needed to stabilise her condition.
It also emerged that she was unaware of the need to use two shots for the most serious allergic reactions and had not received medical training after changing her medication delivery system from the EpiPen to a new Emerade device.
The inquest at St Pancras Coroner’s Court was told an ambulance en-route to the patient had been re-routed because the call was incorrectly categorised as requiring only a category two response, rather than the more serious category one.
It eventually arrived more than 40 minutes after she first contacted the 111 service. Ms Turay-Thomas died later in hospital, with a post-mortem examination identifying acute anaphylaxis as the cause of death.
Coroner Mary Hassell said she would have survived had she been given “appropriately robust training” about treating her condition and administered the correct dose, and had the 111 call handler responded correctly to her condition, and had NHS Digital categorised anaphylaxis as requiring a category one response.
“It only remains for me to say I’m so very, very sorry for the loss of such a young girl,” she added.