Victoria’s coroner has found that measures taken to improve teenager Max McKenzie’s chances of survival likely would not have prevented his death.
Max was just 15 years old when he accidentally ingested walnuts while eating apple crumble at his grandmother’s house in August 2021, causing anaphylaxis and dying in hospital nearly two weeks later.
The coroner’s court is investigating whether doctors and paramedics at Box Hill Hospital provided appropriate treatment.
At a previous hearing, lawyers representing the McKenzie family argued that “substandard care” by paramedics and delays at Box Hill Hospital had prevented Max’s survival.
McKenzie’s family and supporters were in the coroner’s court to hear Thursday’s verdict. (ABC News)
Lawyers for Eastern Health, which oversees Box Hill Hospital, argued that the “probability of death was independent and high.” [Max’s] treatment course.”
The coroner was not satisfied that the death was avoidable.
Today, the coroner told the court that while he did not believe the medical care provided to Max was unreasonable, he agreed that his recovery could have been better supported.
Coroner David Ryan said: “I am not satisfied that his death could have been prevented as a result of the treatment provided by the paramedics and clinicians on the day.”
“That may have been the case, but I’m not satisfied that it was preventable.”
Coroner David Ryan said some treatments could have been given to Max more quickly. (ABC News)
Mr Ryan said Ambulance Victoria (AV) paramedics could have administered the epinephrine sooner, as the injection was given 10 minutes after arriving at the scene.
“Given that he was known to be suffering from anaphylaxis and had already administered an EpiPen, [himself]”Paramedics should have acted within the first five minutes of arriving at the scene,” Ryan said.
The coroner accepted that the need to assess the situation and call in a specialist MICA paramedic had contributed to the initial delay.
Max McKenzie’s parents, Ben and Tamara McKenzie, say their family is disappointed in the health care system. (Included: AMAX4)
Further doses of adrenaline were curtailed because graduate paramedics were not trained to drive ambulances, forcing more qualified paramedics to take the wheel.
“Ideally, if the MICA paramedics had been assisted by more qualified paramedics, they could have administered more adrenaline in the ambulance on the way to the hospital,” he said.
Mr Ryan told the court that Max’s condition was further complicated by delays in opening his airway after he arrived at Box Hill Hospital.
Father performs CPR on dying son, trial heard in court
While paramedics handed him over to hospital staff, the boy suffered a seizure, and despite a ventilator being used to help him breathe, the amount of oxygen in his blood continued to drop.
At this point, Max’s father Ben McKenzie, who works as a paramedic, arrived and began CPR on his son.
The coroner found that Max required immediate intubation, but attempts began 15 minutes after arrival, with several failures, partly due to Max’s vomiting.
An investigation into the ceremonial occasion found delays in adrenaline administration and intubation. (Source: AMAX4)
After doctors made an incision in Max’s neck, they were finally able to intubate him, but MacKenzie still helped treat him by pushing his finger into the opening and threading the tube through.
“It was clear to the ED doctor that Max could not be oxygenated effectively and that a decision to proceed with intubation would have to be made within minutes of arriving in the emergency room,” the coroner said.
“Emergency doctors’ priority was to stabilize Max in preparation for intubation and were understandably concerned about the risk that intubation could cause cardiac arrest.
“However, I believe that the risks associated with intubation were greater than the risks of delaying the procedure, which was the only treatment option that appeared to be effective given Max’s critical condition.”
An inquest heard there was a delay in intubating Max McKenzie at Box Hill Hospital. (ABC News: Patrick Rocca)
The coroner also found that Max’s intubation was delayed while waiting for the wider team to arrive, identify the team leader and take over.
“Max’s condition required a faster response from suitably qualified and experienced clinicians already in the emergency department.
“If he was to survive, it was necessary to establish a safe airway as quickly as possible and it would have taken only a short time to make that clear to everyone present.”
Max went into cardiac arrest soon after, but Mr Ryan said it was likely that even an early airway opening would not have prevented it, as he had symptoms of bradycardia before entering the ambulance.
“The mortality rate was pretty high at this stage because he was already showing symptoms of bradycardia,” Ryan said.
“He is one of those rare cases who doesn’t respond to the initial symptoms of adrenaline.”
Max was then taken to the Alfred Hospital, where he regained consciousness but suffered an acute brain injury and was then transferred back to the Royal Children’s Hospital, where he died after going into cardiac respiratory arrest.
The coroner found that this was Max’s cause of death, and that anaphylaxis was a serious event from which “he never really recovered.”
Further recommendations regarding ambulance procedures
The coroner referred to previous recommendations made in the Safer Care Victoria report carried out by Eastern Health and AV, but made additional recommendations in relation to AV’s treatment plan and training.
Mr Ryan recommended that the AV guidelines for the treatment of asthma and anaphylaxis be reviewed to ensure consistency in relation to adrenaline therapy.
He also recommended that new graduate paramedics undergo emergency driver training during an induction period before entering clinical practice on the road.
AV acknowledged the coroner’s findings and said it would comply with the recommendations.
An AV spokesperson said: “Our deepest sympathies and thoughts remain with the McKenzie family on the devastating loss of Ambulance Victoria.”
“Ambulance Victoria takes our commitment to patient safety very seriously and is committed to continually improving the care and services we provide to our communities.”
Max’s father said it had been a long journey to hear the findings confirming Max’s death could have been avoided.
“But for me, as an emergency physician who had to be there and take part in his treatment, I feel that his death was absolutely preventable. Max shouldn’t have died,” Dr. McKenzie said.
The McKenzie family said Thursday’s results make them feel vindicated that their son’s medical treatment was not best practice. (ABC News)
His mother, Tamara McKenzie, said the family has fought to ensure that Max’s treatment was not best practice or best care.
“Max was let down at different points and in different ways from the moment his medical care was provided,” she said.
Since Max’s death, the MacKenzies have been working on AMAX4, an initiative aimed at reducing and preventing unnecessary deaths related to anaphylaxis and asthma by establishing a standard of care.
“The most shocking part was being told by Eastern Health that Max’s treatment had been best practice for four-and-a-half years,” Dr. McKenzie said.
“Finally, we have validation that this is not the case. That gives us a great sense of relief.”