(CNN)The labeling on a sandwich eaten by a 15-year-old girl who later died from an allergic reaction was "inadequate," a UK medical coroner has said.
Pret a Manger sandwich labeling ruled 'inadequate' after girl's death
The coroner found that Natasha Ednan-Laperouse, who fell ill on a British Airways flight to Nice, died of anaphylactic shock, the Press Association reported.
The teenager bought the olive tapenade and artichoke French bread sandwich from a branch of the international Pret a Manger fast food chain at Heathrow airport in London before boarding the flight in July 2016.
The coroner, Sean Cummings, said the baguette contained sesame, to which she was allergic. "There was no specific allergen information on the baguette packaging or on the (food display cabinet) and Natasha was reassured by that," he ruled.
Around 25 minutes into the flight Natasha's throat became itchy, her face went red and then hives appeared on her body, the coroner said.
Her father gave her two doses of the adrenaline injection pen, Epipen, which is used to treat severe and life-threatening allergic reactions, but the teenager's condition continued to deteriorate.
She said "daddy, help me, I can't breathe", the coroner wrote. Oxygen was provided but Natasha lost consciousness.
As the plane came into land she suffered a cardiac arrest, and despite a doctor's attempts to revive her, and the use of a defibrillator at Nice airport, she died.
BA crew had not told the doctor that there was a defibrillator on board the aircraft. "Whilst I consider this to be an omission on the part of the BA crew, I do not believe this made a material difference to the outcome," the coroner said.
He said he would now make a report to Environment Secretary Michael Gove over the use of food labeling in sotres.
Earlier this week the inquest was told the Pret packaging failed to mention that sesame seeds were "hidden" in the dough.
An allergen chart posted on Pret's website on Tuesday states that the artichoke and tapenade baguette contains sesame.