Finding into death of James Harilaos Tsindos

Contributing factors

• biphasic anaphylaxis secondary to cashew nut ingestion
• delayed recognition of recurrent anaphylaxis symptoms (wheeze)
• delay in administration of third dose of IM adrenaline
• assignment of ATS Category 3 instead of Category 2 at triage
• concurrent RSV infection
• poorly controlled asthma
• asthma as risk factor for severe food anaphylaxis
• prolonged ingestion of allergen (cashews in sauce) causing continued exposure
• possible communication breakdown regarding wheeze between ambulance handover and triage nurse
• inadequate initial assessment of respiratory symptoms as indicator of anaphylaxis rather than asthma alone
• COVID-19 pandemic restrictions affecting triage process and isolation practices
• respiratory arrest preceding cardiac arrest with suboptimal ventilation strategy

Coroner's recommendations

1. Royal College of General Practitioners should utilise the learnings of James' case to develop and distribute further information and guidelines regarding education and clinical support to families with children and adolescents with food allergies who suffer asthma, noting the importance of asthma management and comprehensive allergy testing.
2. Safer Care Victoria should give consideration to utilising the learnings from James' case to develop a statewide approach to the treatment of anaphylaxis such as the ANZCA pathway/cards or guidelines, with a view to enhancing safety of emergency department responses to anaphylaxis and increasing awareness of biphasic or recurrent anaphylaxis.
3. Ambulance Victoria should give consideration to the appropriateness of paramedics carrying EpiPens when responding to presentations of anaphylaxis.
4. Ambulance Victoria should utilise the learnings of James' case to highlight the work instruction WIN/OPS/333 Paramedic Roles: Health Service Interface and Patient Handover, particularly the requirement to reach agreement with ED clinician on 'ambulance handover complete' and enter agreed time in VACIS.
5. The Department of Health should give consideration to requiring that all Food Safety Supervisors undertake food safety training which includes comprehensive food allergen management training, consistent with New South Wales, noting the free training module developed in consultation with Allergy & Anaphylaxis Australia.
6. The Department of Health should give consideration to utilising Best practice guidelines for food allergen management for online ordering being developed by the National Allergy Council and Allergy & Anaphylaxis Australia, with a view to minimising risk of adverse allergic reaction from inadvertent exposure to allergens for people ordering food online.
7. The Department of Health should task the Food Safety Unit to action identified ways to improve safety around vegan dishes online, including consideration of consumer education and reform to relevant food labelling laws with specific reference to labelling of plant-based or vegan food substitutes, to ensure consistency with definitions under the Food Standards Code.
8. The Australian Resuscitation Council should give consideration to reviewing its guidelines related to asthma and anaphylaxis settings, including whether there should be separate guidance for the resuscitation of primary respiratory arrest, with a view to enhancing acute cardiac resuscitations.