Coronial
NSWhospital

Inquest into the death of Jeremy Webb

Deceased

Jeremy Webb

Demographics

16y, male

Coroner

Decision ofDeputy State Coroner Forbes

Date of death

2022-06-11

Finding date

2026-02-26

Cause of death

Anaphylaxis due to mammalian meat allergy after tick bite, causing an acute exacerbation of asthma, which progressed to status asthmaticus

AI-generated summary

Jeremy Webb, 16, died from anaphylaxis due to mammalian meat allergy (tick-induced) which triggered status asthmaticus. He had experienced red meat reactions since age 10 and a severe respiratory event in April 2021 that was diagnosed as asthma without consideration of anaphylaxis. This represented a missed diagnostic opportunity, as the presentation had atypical features consistent with anaphylaxis, and recognition would have led to adrenaline autoinjector prescription. On the night of his death, after eating beef sausages while camping, he developed rapid-onset severe respiratory distress and died despite ambulance adrenaline administration. Key clinical lessons: awareness of mammalian meat allergy among clinicians is essential, particularly in high-prevalence areas; atypical presentations of anaphylaxis may mimic asthma; differential diagnosis should be considered in severe unexplained respiratory events; and early specialist referral for suspected anaphylaxis is critical.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicineallergy and immunologyrespiratory medicinepaediatricsforensic medicine

Error types

diagnosticcommunicationsystem

Drugs involved

adrenalinesalbutamolantihistaminessteroids

Clinical conditions

anaphylaxismammalian meat allergystatus asthmaticusacute asthma exacerbationalpha-gal syndrome

Contributing factors

  • Lack of clinician awareness of mammalian meat allergy in 2021-2022
  • Failure to include anaphylaxis as differential diagnosis on 3 April 2021 hospital admission despite atypical features
  • No referral to specialist following April 2021 presentation
  • Absence of adrenaline autoinjector prescription
  • Delay in adrenaline administration on night of death (approximately 30 minutes after symptom onset)
  • Consumption of beef sausages, which have higher alpha-gal concentration due to offal content and fat
  • Pre-existing asthma and atopy

Coroner's recommendations

  1. CCLHD incorporate into its education program on Management of Allergy and Anaphylaxis provided every ten weeks to Emergency Department Junior Medical Officers information regarding mammalian meat allergy as a potential cause of anaphylaxis
  2. CCLHD insert an additional slide concerning the atypical features of the presentation of anaphylaxis in mammalian meat allergy
  3. CCLHD amend the Alerts on its Procedure on Paediatric Allergy (including anaphylaxis) Assessment and Management to refer to the increasing prevalence of mammalian meat allergy on the east coast of Australia
  4. CCLHD replace reference to 'Wart Off' with 'Tick Off' in allergy procedures
  5. CCLHD amend the tick removal alert to include that tick removal methods may cause or exacerbate development of mammalian meat allergy
  6. CCLHD develop a training module for Emergency Department registrars on mammalian meat allergy addressing prevalence, cause, exacerbation by repeated tick bites, strategies for avoiding further tick bites, importance of comprehensive food history, features and variability of presentation, triggers, discharge summary recommendations including referral to immunologist, and use of Jeremy's case as an illustrative de-identified study
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