Max Mckenzie: Medical workers 'robbed' child of chance at survival

Hospital staff and paramedics “robbed” a 15-year-old boy of his best chance at survival by failing to intervene earlier after he suffered an allergic reaction, his grieving parents say.

Melbourne teen Max McKenzie died in August 2021 after suffering a cardiac arrest and an acute brain injury following his admission to hospital for an anaphylactic shock.

He was allergic to peanuts and tree nuts when he ate apple crumble at his grandmother’s house.

Neither Max nor his grandmother were aware the dessert contained nuts and he suffered an anaphylactic reaction soon after.

He told his mother he felt sick, and administered an EpiPen and ventolin as he also suffered from asthma, before his father Ben - an emergency physician - called an ambulance.

Max’s condition deteriorated rapidly in the hours after and, while being loaded into an ambulance, he expressed concerns he was going to die.

He died in hospital on August 19 after scans found he had suffered an acute brain injury.

Victorian coroner David Ryan held an inquest into Max’s death and the interventions given to him in the lead-up and on Thursday found several steps were missed by medical professionals.

This included by paramedics, who failed to give him adrenaline at the earliest opportunity, and medical staff at Eastern Health’s Box Hill Hospital, who did not intubate him soon enough.

Earlier and more adrenaline, and quicker establishment of an airway via intubation upon arrival at hospital, “would have given him the best opportunity for survival”, the coroner said.

“However, I am not satisfied that his death was preventable as a result of the treatment by paramedics and clinicians on that day,” he said.

“It may have been, but I am not able to be comfortably satisfied that it was preventable.”

Mr Ryan said the circumstances were “rare and incredibly challenging” for all medical professionals.

He found a graduate paramedic should have driven the ambulance with lights and sirens to hospital, allowing her instructor and an intensive care paramedic to care for Max in the back.

The coroner recommended Ambulance Victoria review its guidelines for the treatment of patients with asthma and anaphylaxis, to ensure consistency in administration of adrenaline.

He also recommended graduate paramedics undergo emergency driving training before they hit the road, to ensure more experienced workers were in the back treating the patient.

Outside the court, Max’s parents expressed their concern over missed opportunities to save their son’s life.

“It’s been four-and-a-half years to get to these coronial findings, it’s been a long journey,” Dr McKenzie said.

“While not every aspect or concern we have about Max’s care was able to be addressed today, the coroner found that Max should’ve got more adrenaline from Ambulance Victoria and he should’ve been intubated on arrival at Eastern Health Hospital.

“Those two things didn’t happen, and they robbed Max of his best chance of survival.

“Max should not have died.”

Dr McKenzie gave CPR to his son after he was taken to hospital on August 6, which he said should never have happened.

“I should never have had the opportunity to participate in Max’s resuscitation because it should have been done before I got there and I think the coroner has highlighted that today,” he said.

Max’s mother said the hospital told them their care of the 15-year-old was “best practice and today the coroner has told us it wasn’t”, as she asked for a “heartfelt apology” from Eastern Health.

“Max was let down in so many ways, at so many points in time, and the coroner has found two points where Max’s care was not appropriate and not OK,” she said.

Ambulance Victoria and Eastern Health have been contacted for a response.