Finding into death of Ronak Satyajit Warty

Contributing factors

• ingestion of mislabelled packaged food containing undeclared milk allergen
• delay in administration of EpiPen due to needle phobia
• possible unrecognised chronic asthma
• environmental pollen sensitisation prior to reaction
• absence of mandatory reporting mechanism for anaphylaxis cases to food regulators
• failure of medical professionals to report suspected mislabelled food product to food safety authorities

Coroner's recommendations

1. The Secretary of the Victorian Department of Health and Human Services should investigate, consult widely and formulate a program for mandatory reporting for children who present at hospitals and emergency departments with anaphylaxis
2. The mandatory reporting program should include interrogation of sources of anaphylaxis, with direct referral to the Food Safety Unit if a packaged foodstuff or its labelling is implicated
3. The Secretary should encourage the Food Safety Unit to action identified ways to improve reporting of food allergen-related incidents and provide educative information to members of the public with food allergies and their parents, and to the medical community
4. The Victorian Minister for Health should support formulation of a mandatory reporting scheme for children with anaphylaxis presenting to hospitals and emergency departments, by proposing appropriate legislation