A woman with a severe allergy lay dying in the street while customers continued to be served at a Pret a Manager, an inquest has heard.
Celia Marsh, 42, died on 27 December 2017 after eating a super-veg rainbow flatbread from a Pret in Bath.
The wrap had traces of milk protein in it despite being labelled as dairy free.
The mother-of-five suffered from a severe dairy allergy and Avon Coroner’s Court was told she “religiously avoided” all dairy products following a near-fatal allergic reaction months earlier.
She purchased the wrap at 2.08pm, and within 15 minutes entered into acute anaphylactic shock.
She was declared dead at 4pm.
Brendan Turvey, a civil servant with first aid training who went to help Mrs Marsh, said a crowd had formed in the busy street around her as she lay on the ground.
He described the scene as “disturbing” and said he saw Mrs Marsh's husband Andy Marsh attempting to comfort his young daughter.
A number of people were said to have taken off their coats to place over Mrs Marsh to keep her warm.
However, Shawn Eyles, one of the paramedics who attended, said in his statement that some shoppers continued to step over Mrs Marsh as she was being treated.
On Thursday a coroner at Avon Coroner’s Court in Bristol, concluded that the yoghurt manufacturer had documentation warning it of the risk of cross-contamination of the starch.
The CoYo branded yoghurt, which is Australian, was licenced for manufacture in the UK to a company called Planet Coconut.
Bags of the HG1 starch, produced by Tate and Lyle PLC, carried the warning “manufactured in a factory that handles milk, eggs, cereals containing gluten, sulphur dioxide and sulphites”.
Coroner Maria Voisin said Pret a Manger had not been alerted to the risk, and that the yoghurt was labelled as “dairy free”.
Speaking outside of the inquest, Mrs Marsh’s daughter Ashleigh Grice said: “It is now almost five years since our mum Celia was taken from us, she knew she had a serious food allergy – because of that constant fear mum was extremely cautious in all she ate, checking every label, often triple checking, for dairy.
“On that terrible day she trusted the ‘dairy free’ labelling in the Pret a Manger store, but the vegan wrap had been contaminated with milk protein.
“The contents was poisonous to her and she collapsed in the street.”
Mrs Marsh’s death came in the wake of that of 15-year-old Natasha Ednan-Laperouse, who died in 2016 after eating a Pret baguette containing sesame seeds bought at Heathrow Airport.
Ms Ednan-Laperouse had a sesame allergy.
The tragedy sparked an overhaul of food labelling laws which now requires retailers to display full ingredient and allergen labelling on every food item made on the premises and pre-packed for direct sale, including sandwiches, cakes and salads.