Coroner Rules Teen's Anaphylaxis Death "Unlikely Preventable" Despite Missed Opportunities

A Victorian coroner has concluded that the death of 15-year-old Max McKenzie, following accidental walnut ingestion and anaphylaxis in August 2021, was unlikely to have been prevented. This finding comes despite an acknowledgment that steps could have increased his chance of survival.

Coronial Findings

Coroner David Ryan stated that the medical care provided to Max was not considered unreasonable, but his recovery could have been better supported.

He was not satisfied that the death was preventable due to the treatment from paramedics and clinicians on that day, noting it 'may have been, but I am not able to be comfortably satisfied that it was preventable'.

Paramedic Response: Adrenaline Delays

Ambulance Victoria (AV) paramedics could have administered adrenaline more quickly, specifically within the first five minutes of arriving at the scene, rather than 10 minutes later.

Initial delays were partly attributed to the assessment of the situation and the need to call in a specialist MICA paramedic. Further adrenaline administration was hindered because a graduate paramedic was untrained to drive the ambulance, requiring the more qualified paramedic to drive.

Hospital Care at Box Hill Hospital: Airway Challenges

Max's condition was complicated by a delay in establishing an airway upon his arrival at Box Hill Hospital. Despite ventilation, his blood oxygen levels continued to drop after a seizure during handover.

Max's father, an emergency physician, arrived and began CPR on his son. The coroner found that immediate intubation was required, but attempts began 15 minutes after arrival and faced difficulties, including Max vomiting. Intubation was eventually successful after a doctor performed a tracheotomy, with Max's father assisting.

The coroner stated that emergency physicians prioritized stabilizing Max and were concerned about cardiac arrest risk from intubation. However, the risks of delaying the procedure outweighed these concerns, as intubation was the most likely effective treatment. Further intubation delays occurred while waiting for a broader team, identifying a team leader, and conducting a handover, despite suitably qualified clinicians being present.

Cause of Death: Cardiac Arrest Deemed Unlikely Preventable

Max went into cardiac arrest shortly after. The coroner deemed this unlikely preventable, even with earlier airway establishment, due to Max experiencing bradycardia before entering the ambulance. Max was identified as one of the rare cases that do not respond to initial adrenaline doses.

He was later transferred to Alfred Hospital, where he regained consciousness but sustained an acute brain injury, then moved to Royal Children's Hospital, where he died from cardiac respiratory arrest. The anaphylaxis was identified as a significant event from which he never fully recovered.

Recommendations and Family's Call for Change

The coroner noted previous recommendations implemented by Eastern Health and AV from a Safer Care Victoria report. Additional recommendations include AV reviewing its guidelines for asthma and anaphylaxis treatment to ensure consistency in adrenaline therapy. He also recommended graduate paramedics undergo emergency driver training during their induction period before starting on-road clinical practice.

Ambulance Victoria acknowledged the findings and expressed sympathies, committing to continuous improvement.

Max's father, Dr. Ben McKenzie, believes his son's death was preventable.

The McKenzie family stated the findings provided a sense of vindication, confirming their belief that Max's care was not best practice after being told it was for years.

They have since launched AMAX4, an initiative to reduce deaths from anaphylaxis and asthma by establishing a standard of care.