Pret a Manger’s allergy labelling was inadequate, the coroner in the case of a girl who died after eating a baguette from the food chain has said.

Natasha Ednan-Laperouse, 15, died after eating a Pret a Manger artichoke and olive tapenade baguette bought from Heathrow Airport in 2016. She had severe allergies to many foods including sesame, which had been baked into a baguette, the ingredients had not been listed on the packaging. She collapsed during a flight from Heathrow to Nice, despite her father administering two EpiPen injections.

She was “reassured” by the lack of specific allergen information on the packaging, the coroner found.

Pret a Manger confirmed at the time of death that products would not have been individually labelled with allergen or ingredient information, which was within regulations.

EU Regulations and UK legislation require no allergen labelling on products that are not prepacked, or are prepacked for direct sale. However, the retailer is required to prompt consumers to ask about allergens by signposting by a notice where the intending purchaser chooses their food and have allergen information available.

At the inquest, the acting senior coroner for West London Dr Sean Cummings said that “it seems strange” that a local sandwich shop can benefit from that regulation but “that an organisation that sold 218 million items a year could also benefit”. He added that “a cynic might think it was almost a device to get round regulation relating to information on food allergens”

Cummings also questioned Pret a Manger’s handling of sesame at a time when there were six previous allergic reactions involving the same bread in the previous year. Dr Cummings said he would be writing to Pret a Manger about its practices of collecting information on allergic reactions and responding to serious concerns.

“I was left with the impression that Pret a Manger had not addressed the fact that monitoring food allergy in a business selling more than 200 million items year was something to be taken very seriously indeed,” Dr Cummings said.

Coroner Dr Sean Cummings said he would be reporting to the government over whether large businesses should be able to benefit from regulations that allow reduced food labelling for products made in shops.

Environmental secretary Michael Gove has already said the family of Ednan-Laperouse was “absolutely right” in its belief the law needed to be changed. He has instructed civil servants to investigate such a change.

Pret a Manger is to start trialling new labels that show full ingredients, including allergens, on packaging in all UK shops as quickly as possible.

Environment Secretary Michael Gove said: “This is a deeply upsetting situation and my heart goes out to the family of Natasha Ednan-Laperouse.

“We are currently reviewing our approach to food labelling to give consumers more information. We await the findings of the inquest and stand ready to take appropriate action.”

The Prime Minister also told BBC Breakfast: “This was an absolutely tragic case and our thoughts are with [Natasha’s] family and friends over what happened.

“We have obviously to look at this issue, we have to look at the responsibility of individual companies as well.

Pret a Manger again found itself on the defensive again after it subsequently emerged that a second customer collapsed and died on 27 December last year after eating a vegan super-veg rainbow flatbread allegedly contaminated with milk protein. An inquest has yet to be held and there is dispute between Pret a Manger and its supplier CoYo as to the root cause.