Food labelling laws were "playing Russian Roulette" with the life of a teenager who died after eating a Pret a Manger sandwich, her father says.
Natasha Ednan-Laperouse, who had a severe sesame allergy, died after eating an artichoke, olive and tapenade baguette that did not label all the ingredients.
The coroner called Pret a Manger's allergy labelling "inadequate" on the final day of the inquest into the death of the 15 year old who fell ill on a BA flight from London to Nice.
He found the teenager was "reassured" by the lack of specific allergen information on the packaging of the sandwich, and said he would be writing a report to the government on his concerns about allergen labelling.
Our beloved daughter died in a tragedy that should never have happened. If Pret a Manger was following the law, then the law was playing Russian Roulette with our daughter's life. It's clear that the food labelling laws as they stand today are not fit for purpose and it's now time to change the law. Natasha's inquest should serve as a water shed moment to make meaningful change and to save lives.
Saying the company is "deeply sorry" for Natasha's death, the CEO of Pret a Manger Clive Schlee told reporters: "We want meaningful change to come from this tragedy. We will ensure that it does."
The teenager, from Fulham, was travelling with her father and her best friend for a holiday in July last year, when she went into anaphylaxis.
A video released by her family shows her smiling at the camera on the plane prior to takeoff, shortly before she became ill.
The coroner Dr Sean Cummings detailed how Ms Ednan-Laperouse began to suffer an allergic reaction on the flight.
She said to her father, “Daddy please help me I can’t breathe,” and he injected her twice in the same leg with her EpiPen.
The court was told the second may not have been effective as it was administered to the same leg.
“Mr Laperouse I cannot imagine how that experience was on that plane,” Dr Cummings said to Natasha's father Nadim Ednan-Laperouse MBE.
“Terrible,” he replied.
Despite the injections being administerd, the 15-year-old was pronounced dead hours later at a hospital in Nice.
The coroner added he will be writing to Pret about collecting information on allergic reactions.
Dr Cummings said: "Natasha Ednan-Laperouse died of anaphylaxis in Nice on July 17 2016 after eating a baguette, purchased from Pret A Manger at London Heathrow's Terminal 5.
"The baguette was manufactured to Pret specifications and 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."
Earlier in the five-day hearing the inquest was told the packaging failed to mention that sesame seeds were "hidden" in the dough.
It also emerged that a "specific warning" about the dangers of not signposting the allergen had been given to the food chain the previous year.
The court heard how the chain had made use of reduced allergen labelling requirements for shop-made food - which is intended to benefit smaller, independent stores.
Dr Cummings said on Wednesday: "It seems a little strange a local sandwich shop could benefit from that regulation but an organisation that sells 218 million items (a year) should also benefit from that regulation.”
The coroner continued: "A cynic might think it was almost a device to get around regulations relating to identifying food allergens."
Under EU regulations, food companies are required to warn customers about allergy risks either on signs and packaging or orally, usually meaning they are told to inquire themselves.
Pret chose to deliver allergy information orally and was supposed to have stickers within fridges telling customers to ask staff members for details, the inquest heard.
British Airways cabin crew were also questioned over their response after the inquest heard that the on-board defibrillator was not used in-flight.
Mario Ballestri, who helped junior doctor Thomas Pearson-Jones as he performed CPR on Natasha, said it would have been too dangerous to get the device from the other end of the aircraft when she went into cardiac arrest minutes before landing.
The inquest heard that a defibrillator was used on Natasha after landing when Nice paramedics arrived.
Speaking after the inquest the CEO of Pret a Manger Clive Schlee said: "We are deeply sorry for Natasha’s death. We can’t begin to imagine the pain and grief her family has had to deal with. We have listened to everything the coroner and Natasha's family has said this week. We will learn from this. All of us at Pret want meaningful change to come from this tragedy. We will ensure that it does."
Dr Cummings will make a report to environment secretary Michael Gove over whether large businesses should be able to benefit from regulations that allow reduced food labelling for products made in shops.