A Victorian coroner has ruled that while the death of 15-year-old Max McKenzie following an anaphylactic reaction was unlikely to have been prevented, steps could have been taken to increase his chances of survival. The inquest, concluding today, , examined the medical care provided to Max after he accidentally ingested walnuts in August 2021.
Max’s case highlights the critical need for swift and appropriate medical intervention in anaphylaxis, a severe and potentially fatal allergic reaction. He had unknowingly consumed walnuts in an apple crumble at his grandmother’s home, triggering the reaction. The subsequent investigation focused on the actions of both paramedics and staff at Box Hill Hospital.
Delays in Adrenaline Administration and Airway Management
The coroner’s findings identified key areas where care could have been improved. Specifically, Ambulance Victoria (AV) paramedics could have administered adrenaline more quickly. The initial dose was given 10 minutes after their arrival on scene, whereas the coroner stated that, given Max’s known allergy and self-administration of an EpiPen prior to their arrival, adrenaline should have been administered within the first five minutes.
The delay was partially attributed to the need to assess the situation and call for a specialist MICA (Mobile Intensive Care Ambulance) paramedic. However, the coroner emphasized that a more rapid response with adrenaline could have been beneficial. Further administration of adrenaline was also hindered by the fact that the graduate paramedic on scene lacked the training to drive the ambulance, requiring the more experienced paramedic to handle that responsibility.
Upon arrival at Box Hill Hospital, further delays occurred in establishing a secure airway for Max. The coroner found that intubation – the insertion of a tube to help with breathing – should have been initiated immediately. Attempts were delayed for approximately 15 minutes, and were initially unsuccessful due to Max vomiting. Intubation was achieved only after a doctor made an incision in Max’s neck, with his father, Ben McKenzie – an emergency physician himself – assisting in the procedure.
A Father’s Desperate Intervention
The circumstances surrounding Max’s care at the hospital were particularly distressing for his family. Dr. McKenzie found himself performing CPR on his own son after paramedics handed over his care to hospital staff. He expressed his profound belief that he should not have been in that position, stating, “I should never have had the opportunity to participate in Max’s resuscitation because it should have been done before I got there.”
The coroner acknowledged that the hospital staff were legitimately concerned about the risk of cardiac arrest associated with intubation, but concluded that the risks of delaying the procedure outweighed those concerns. He emphasized that establishing an airway was the most critical step in Max’s care and should have been prioritized.
Complexities and Contributing Factors
While the coroner identified areas for improvement, he stopped short of stating that Max’s death was preventable. He noted that Max had experienced an episode of bradycardia (slow heart rate) before arriving in the ambulance, suggesting that his condition was already severely compromised. He also acknowledged that Max was one of the rare cases that does not respond to initial doses of adrenaline.
Despite this, the coroner’s report highlighted systemic issues that contributed to the delays in care. These included delays in identifying a clear clinical leader for Max’s resuscitation at the hospital and a lack of immediate action in establishing an airway upon his arrival in the emergency department.
Recommendations for Improved Anaphylaxis Management
Following the inquest, the coroner made several recommendations aimed at improving anaphylaxis management. These include a review of Ambulance Victoria’s guidelines for adrenaline therapy and the provision of emergency driver training for graduate paramedics. These recommendations build upon previous improvements already implemented by Eastern Health and AV following a Safer Care Victoria report.
The McKenzie family has been tireless advocates for improved anaphylaxis awareness and management since Max’s death, establishing the AMAX4 initiative to promote a standardized approach to care. They expressed relief at the coroner’s findings, which validated their belief that Max’s care was not optimal.
“Max was let down in so many ways, at so many points in time, from the minute healthcare came to him,” said Tamara McKenzie, Max’s mother. Dr. McKenzie added, “To finally have the validation that that’s not the case…that gives us intense relief.”
This case serves as a stark reminder of the speed and precision required in managing anaphylaxis. While the coroner’s findings do not definitively assign blame, they underscore the importance of adhering to established protocols, prioritizing airway management, and ensuring that healthcare professionals are adequately trained to respond to this life-threatening emergency.
