Finding into death of Catherin D'Rozario

Contributing factors

• Known food allergies (sesame, nuts, fish, bananas) not managed by specialist assessment
• Did not carry EpiPen despite GP recommendation 2-3 years prior
• Consumption of food at Asian restaurant with known allergen risks
• Probable cross-contamination with sesame or other allergen at restaurant
• Delayed recognition and emergency response while with friends
• Possible insufficient prior specialist immunology assessment and education

Coroner's recommendations

1. The Royal Australian College of General Practitioners, the Royal Australian College of Physicians and in consultation with the Australian Society of Clinical Immunology and Allergy should work collaboratively to educate their members and fellows about the dangers of food allergies and anaphylaxis, and consider referring all patients (especially children and young persons) who present with food allergies to a specialist immunologist or immunology clinic such as that at the Royal Children's Hospital for assessment and management
2. The Australian Society of Clinical Immunology and Allergy, the Victoria Department of Education and the Victorian Department of Health should consult widely and work collaboratively towards establishing an educational program directed to parents, teachers and students of schools and universities alerting them to the potentially fatal consequences of food allergies and anaphylaxis