A teenager who died after eating a Pret a Manger baguette was the 10th person to have had an allergic reaction to sesame at the chain, an inquest heard.
Natasha Ednan-Laperouse, from Fulham, west London, collapsed on a BA flight from London to Nice on 17 July 2016 after eating an artichoke, olive and tapenade baguette purchased from a Pret store at Heathrow Airport.
The 15-year-old, who was at the start of "the best summer ever", suffered a fatal reaction to sesame, which she did not realise was in the bread.
The packaging failed to mention sesame seeds were "hidden" in the dough, an inquest at West London Coroner's Court heard.
Natasha was given two EpiPen jabs on the flight after she started to react, but she eventually suffered cardiac arrest and died at a hospital in Nice.
It emerged on Tuesday that the popular chain had been given a "specific warning" about the dangers of not putting signage up about the allergen the year before.
A complaint log for the company from 17 July 2015 and 29 June 2016 revealed nine sesame-related allergy incidents.
Four of those customers had to go to hospital and another went to a medical centre because of their reactions.
Six of the nine cases were because of "artisan baguettes", the type used for Natasha's sandwich.
One of the women who had a reaction contacted lawyers representing Natasha's family after reading how she had died.
Jeremy Hyam QC told the inquest the woman had nearly died after going into anaphylactic shock from sesame in a Pret sandwich nine months before Natasha's death.
The woman, who was 17 at the time, said her father is a doctor and helped prevent the episode from being fatal.
In an email, she said her mother, also a doctor, had written to Pret as she was shocked allergy information was only available upon request.
The email read: "My mother expressed her alarm at this and warned that, in her opinion, other similar adverse events could easily occur."
Mr Hyam said Pret failed to label sandwiches with allergy information, despite a "clear concern being repeatedly raised that artisan baguettes were causing sesame seed allergy problems".
Johnathan Perkins, Pret's risk and compliance director, said: "We responded appropriately to each individual complaint at the time."
But it took a year after the complaint for Pret to change the design of labels within fridges telling customers to ask staff for allergy information, which are required by EU law.
And a photo of the Heathrow branch where Natasha bought the sandwich, taken eight days after her death, appeared to show no allergy sticker in the fridge.
A Hillingdon Council food officer, who visited the Terminal 5 branch unannounced in 2017, also reported no allergy stickers at tills.
There was also a severe issue with Pret's chocolate croissant, which was not labelled as containing hazelnut. At least three people are known to have had an allergic reaction.
Mr Perkins accepted some people had a "tragic experience", but said "thousands of allergy sufferers come through our doors and are able to shop safely".
Reflecting on Natasha's death, he said: "The parent in me would want to change everything. The professional in me has to remain grounded.
"The learning for me is that humans are fallible in their actions, we will at some times get things wrong."
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He said Pret was committed to making its allergy policy as simple and consistent as possible.
The inquest is due to last until Friday.
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