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miscommunication and assumptions
I think this is exactly right, compounded by gaps in staff training and badly designed SOP. I know of two incidents in 5 star London hotels in the past 12 months where cakes containing nuts were served to guests who had explicitly declared a nut allergy to their server.
It must be horrendous living with a serious allergy and having to play Russian roulette every time you eat out.
That’s rubbish! This case looks like miscommunication and assumptions, compounded by other issues. Most dental practices have an Epipen or another AAI for example.