Finding into death of Jack Glen Irvine

Contributing factors

• Consumption of macadamia nut cookie containing allergen despite prior notification of nut allergy
• VKA failure to implement policies and procedures for managing children with identified food allergies
• VKA failure to disseminate collated allergy information to volunteers and food organisers
• No labelling or identification of food allergen content on cookie platter
• Absence of provided food specifically accommodating identified dietary restrictions
• Failure to provide Jack's Action Plan for Anaphylaxis to VKA organisers
• Failure to provide Jack's EpiPen and medication details to VKA organisers
• Jack's father's inability to recognise respiratory symptoms as anaphylaxis rather than asthma exacerbation
• Lack of parental education regarding overlap between asthma and anaphylaxis symptoms
• Lack of education regarding delayed onset of anaphylactic symptoms
• EpiPen not administered before emergency services arrival
• Exercise proximate to allergen consumption acting as accelerant
• Concurrent asthma comorbidity increasing anaphylaxis severity

Coroner's recommendations

1. Royal College of General Practitioners and Royal College of Physicians collaborate with ASCIA to produce an information brochure for families with children who have both asthma and anaphylaxis risk, in addition to in-room education and Action Plans
2. Royal College of General Practitioners and Royal College of Physicians collaborate with ASCIA to produce education module/brochure/application for high-risk adolescent group (12-25 years) on food allergy self-management during transition to independence
3. ASCIA review the Action Plan for Anaphylaxis to include guidance for managing suspected allergic reaction versus asthma attack, recommending EpiPen administration followed by Ventolin for breathing difficulties in those with both conditions
4. Subway Systems Australia provide a copy of the Allergen Guide with each catering order so customers have reference material
5. Subway Systems Australia implement mandatory labelling policy for catering orders/packs to identify potential allergens such as nuts
6. Subway Systems Australia mandate display of the Allergen Guide in public areas of all restaurant outlets
7. Victorian Minister for Sport in consultation with Minister for Health consider whether grants under Community Sports Infrastructure Fund be conditional on sporting clubs having policies requiring all staff, volunteers and employees to complete allergy and anaphylaxis training (via first aid training or ASCIA online training)
8. Victorian Karting Association complete a legitimate and meaningful independent review of policies and procedures for safely conducting camps for children, including assessment of volunteer training requirements on allergy and anaphylaxis management and safe food provision