Finding into death of Max Peter McKenzie

Contributing factors

• Refractory anaphylaxis unresponsive to initial adrenaline doses
• Severe bronchospasm
• Delayed administration of first intramuscular adrenaline by paramedics (approximately 10 minutes after arrival rather than within 5 minutes)
• Delayed establishment of intravenous adrenaline infusion
• Delayed intubation attempt by emergency physicians (15 minutes after arrival)
• Difficulty identifying clear team leader during resuscitation
• Multiple failed intubation attempts before cricothyroidotomy
• Profuse vomiting complicating airway management
• Endotracheal tube positioned incorrectly in right main bronchus after cricothyroidotomy
• Hypoxic seizure at scene indicating severe hypoxia
• Underlying asthma as comorbidity complicating anaphylaxis management

Coroner's recommendations

1. Ambulance Victoria review its separate guidelines for the treatment of asthma and anaphylaxis to ensure consistency in relation to adrenaline therapy
2. Ambulance Victoria ensure that graduate paramedics undergo emergency driving training during their induction period before entering on-road clinical practice
3. Consider changes to MPDS call script to identify anaphylaxis with dual diagnosis of asthma
4. Develop Ambulance Victoria Escalation of Care Clinical Practice Guidelines
5. Include critically unwell paediatric education in yearly Ambulance Victoria education
6. Conduct thematic analysis on children with both asthma and anaphylaxis
7. Conduct thematic analysis of paediatric sentinel events
8. Emphasise state-level education on assessment and treatment of acutely unwell children at risk of deterioration
9. Reintroduce multidisciplinary simulation training in emergency departments for critical patient management
10. Contact Australian and New Zealand College of Anaesthetists to develop training scenarios for children with asthma and anaphylaxis with focus on airway management
11. Contact Australian College of Emergency Medicine to develop ACME simulation course scenario for dual diagnosis
12. Introduce mandated roles visible on uniform in emergency departments
13. Create policy directing unassigned staff outside resuscitation areas
14. Engage relevant peak bodies to review anaphylaxis guidelines in setting of asthma
15. Improve and standardise recording of prehospital notifications
16. Review procedures for simplification of handover requirements for critically unwell patients
17. Replace nebuliser delivery devices to prevent small parts falling during use
18. Update Open Disclosure standards to meet Statutory Duty of Candour requirements