[Trigger Warning]
A New Zealand mother has called her son’s death a “senseless waste of a life” after a post-mortem confirmed the 24-year-old died from an allergic reaction caused by trace amounts of peanut in a meal at a mental health respite facility. Riley Brown, a patient at the Nelson facility operated by provider Pathways, suffered fatal anaphylaxis on June 1. His death has led to a formal review by Health New Zealand into the care he received, following the confirmation that his known peanut allergy caused his tragic passing.
The post-mortem, conducted by pathologist Dr Mark Houghton, confirmed Brown’s cause of death was anaphylaxis triggered by a peanut allergy. Notably, a toxicology report on the food Brown ate revealed traces of a peanut allergen — 594.9 parts per million. The report noted this level “exceed[s] both the applicable regulatory thresholds and the typical concentrations expected in products labelled as free from peanut allergens,” confirming that an ingredient in his meal contained the deadly contaminant.
Riley’s mother, Paula Brown, received the post-mortem and toxicology reports from the Coroner’s Court and expressed her horror at the findings, stating she had a “gut feeling” her son’s meal contained nuts, despite earlier assurances to the contrary. Upon reading the documents, she was “horrified” and demanded accountability for the systemic failure. She stated emphatically, “I want them to be made accountable for this, to take accountability.”
The pathologist’s report also contained details on potential complicating factors, including the presence of several medications. Houghton confirmed Brown’s elevated serum tryptase level of 32.3 micrograms per liter was “in keeping with anaphylaxis.” The report also noted the presence of propranolol, a beta-blocker, which “had been reported to block or limit the effects of adrenaline [epinephrine] as a treatment for acute anaphylaxis.” Despite this, Houghton confirmed, “In this case, intramuscular adrenaline was delivered rapidly and appropriately with limited clinical effect.”
Details of the evening of June 1 reveal a swift and ultimately fatal progression of the allergic reaction. Two hours after having dinner at the facility, Riley Brown began to feel unwell, believing he was having an allergic reaction. At 7:20PM, the ambulance was dispatched on a “non-urgent” job for a severe allergic reaction. According to the ambulance summary, Brown was able to walk to the vehicle “saying he couldn’t breathe” but died shortly after at 8:15PM, reportedly going into cardiac arrest while being transferred to the hospital.
For Paula Brown, the grief remains overwhelming four months after her loss. She described the profound personal toll of her son’s death, telling reporters that she was “struggling to get on with life.” She poignantly expressed how central her son was to her life, saying, “Riley was my life,” and lamented, “It’s taken Riley’s life and has destroyed mine.”
In response to the confirmed cause of death, Health New Zealand Regional Lead Vicki Dent offered the organization’s “deepest sympathies and heartfelt condolences” and confirmed a review of the care provided is underway. Mental Health Minister Matt Doocey also weighed in, saying his thoughts were with the family, and acknowledging, “The loss of a child is every parent’s worst nightmare.” He added a clear expectation for the service, stating, “I expect that anyone under the care of New Zealand’s mental health services is provided with safe, high-quality care, and the review must examine whether that standard was met.”
We offer our sincere condolences to Ms. Brown, who is experiencing every parent’s worst nightmare.
It is completely unacceptable for a facility responsible for someone’s care to neglect its duties by poisoning them with their allergen. We expect Pathways to be held accountable and for system-wide changes to be implemented to prevent this from ever happening again.
Although epinephrine was administered before Mr Brown was taken to the hospital, it was evidently not enough to stop the progression of anaphylaxis. Although we don’t know if he was given a second dose, we hope this is investigated.
It is imperative for everyone who has been prescribed epinephrine to take two doses along everywhere, every time, and to administer the first dose when anaphylaxis is first suspected. If symptoms persist after 5 to 15 minutes, administer the second dose and call emergency services.
If you are taking a beta blocker like propranolol, discuss how it might affect the effectiveness of epinephrine with your physician.
