A teenager with a severe nut allergy died in part because of human error, a coroner has ruled.
Shante Turay-Thomas, 18, 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.
Her mother Emma Turay, who said she felt “badly let down” by the NHS, wants an “allergy tsar” to be appointed to help prevent similar deaths.
The inquest heard call staff for the NHS’s 111 non-emergency number failed to appreciate the teenager’s worsening condition was typical of a severe allergic reaction to nuts.
A telephone recording of the 111 call, made by her mother, 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, then 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 the 1,000 micrograms needed to stabilise her condition.
It also emerged 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 that was on its way to the patient had been rerouted 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.
Returning a narrative verdict, 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.
She added she intended to make a prevention of future deaths report highlighting areas of concern.
The teenager’s mother said: “Nothing will ever bring our beautiful Shante back to us but what has kept me going throughout this process is knowing that she would want me to get answers and make sure the same thing doesn’t happen to anyone else.
“The coroner highlighted the fact that no one person in NHS England or the Department of Health is responsible for allergies, and it is quite clear we need an allergy tsar to co-ordinate and implement steps to prevent others from suffering avoidable deaths like Shante’s.”
Tanya and Nadim Ednan-Laperouse, who set up the Natasha Allergy Research Foundation following their own daughter’s death from anaphylaxis, said the inquest “exposed huge systemic failures at all levels of our healthcare system”.
Tsars are advisers who help shape government policy in certain areas pertinent to their expertise.