[Trigger Warning]
A Victorian coroner has issued a scathing assessment of the medical care provided to 15-year-old Max McKenzie, ruling that a series of critical failures—most notably a delay in administering epinephrine—“robbed” the teenager of his chance at survival. Max died in August 2021 of a hypoxic brain injury after an anaphylactic reaction to walnuts. The inquest concluded that although Max was alert and able to articulate his diagnosis upon entering the healthcare system, the subsequent emergency response was marked by “appalling” neglect and a failure to meet basic medical standards.
The findings focused heavily on missed opportunities by paramedics and hospital staff to provide life-saving intervention during the “golden window” of his reaction. State Coroner David Ryan noted that despite Max’s rapidly deteriorating condition, there were significant delays in administering epinephrine and a failure to escalate care. “Earlier and more adrenaline [epinephrine]… would have given him the best opportunity for survival,” the coroner stated, highlighting that the gravity of the situation was underestimated by those tasked with his protection.
Max’s parents, Dr Ben McKenzie—an emergency physician who eventually had to help resuscitate his own son—and Tamara McKenzie, have been vocal about the systemic complacency they witnessed. They described the agony of watching Max slip away while pleading for more aggressive treatment. “The coroner has found two points where Max’s care was not appropriate and not OK,” Tamara McKenzie said outside the court, emphasizing that their initial concerns were dismissed by a system that later claimed his care was “best practice.”
A critical point of failure identified was the paramedics’ on-scene decision-making. The inquest heard that a graduate paramedic should have driven the ambulance with lights and sirens, allowing more experienced staff to focus entirely on Max’s treatment in the back. Instead, the failure to prioritize repeated doses of epinephrine led to Max’s respiratory distress progressing to a fatal cardiac arrest. The coroner recommended that Ambulance Victoria review its guidelines to ensure consistency in epinephrine administration for patients with combined asthma and anaphylaxis.
The neglect continued at Eastern Health’s Box Hill Hospital, where medical staff failed to intubate Max in a timely manner. Evidence showed a 19-minute delay in attempting to secure an airway, a period one expert described as “sealing his fate.” Dr Andrew Numa, a specialist in intensive care, testified that in such a crisis, “the time to act is now,” and that the delay in providing pharmacological support and airway management was catastrophic for the teenager’s brain health.
In the wake of this tragedy, Dr Ben McKenzie has developed the “AMAx4” algorithm, a streamlined approach to treating anaphylaxis designed to prevent the very delays that killed his son. He advocates reform to address the “siloing of expertise” that leaves patients at risk during emergency transitions. “I should never have had the opportunity to participate in Max’s resuscitation because it should have been done before I got there,” Dr McKenzie remarked, calling for a cultural shift in how emergency medicine is practiced.
While the coroner stopped short of saying Max’s death was definitively preventable given the severity of the reaction, he maintained that the medical workers’ failures stripped him of his “best chance.” Both Ambulance Victoria and Eastern Health have since extended their sympathies and acknowledged the findings. For the McKenzie family, the ruling offers a measure of validation, though they remain heartbroken that a “vibrant and talented” boy was let down by the very system designed to save him.
Here is a 9 News report detailing the tragedy:
Our hearts go out to the McKenzie family and we hope the coroner’s findings bring them some modicum of closure.
Max had administered his epinephrine and ventolin when he realized that he was in the midst of a severe reaction, but it was not enough to save his life.
We remind our readers that despite this tragedy, epinephrine is the only drug that can halt and reverse the progression of life-threatening anaphylaxis. If you have been prescribed epinephrine, take two doses along everywhere, every time, and be sure to administer the first when you first suspect anaphylaxis. The second dose can be administered as soon as five minutes later if symptoms do not improve, and emergency services should be notified immediately.
When paramedics arrive, be sure to tell them that you or your loved one is suffering from anaphylaxis and insist on additional epinephrine if symptoms have not eased by then.
