Inquest into the Death of Lynch

Contributing factors

• failure to prescribe or ensure patient carried adrenaline autoinjector despite known peanut allergy and prior anaphylactic reactions
• lack of referral to immunologist/allergist for risk assessment and ongoing management
• inadequate patient education regarding anaphylaxis risk and management
• delayed administration of second dose of intramuscular adrenaline
• absence of consistent anaphylaxis guidelines at regional hospital
• poor allergen management practices at food service venue including cross-contamination risks
• lack of communication to food service staff regarding allergy
• asthma as co-morbidity increasing severity of reaction
• remote location limiting access to specialist care and advanced resuscitation resources

Coroner's recommendations

1. Those at risk of life-threatening anaphylaxis should carry an Epipen at all times, particularly when eating out and travelling to remote places
2. Department of Health should develop a Western Australian model of care for anaphylaxis incorporating immunology/allergy specialists, other specialists, GPs, pharmacists and health professionals with adequate funding and a project officer
3. Department of Health should improve education of health professionals about acute management of anaphylaxis and appropriate followup, develop best practice guidelines regularly updated, provide easy access to ASCIA action plans, adrenaline autoinjector trainers and patient education resources, and ensure access to adrenaline autoinjectors at point of primary care after initial anaphylaxis episode
4. Education of food industry regarding allergens and allergic customers should be improved through training of staff about allergens, accurate labelling, full disclosure of food ingredients and cross-contamination routes, with Environmental Health Officers provided further training for this purpose
5. Path West Laboratory Medicine WA should retain blood samples, stomach contents and food samples in all cases of suspected anaphylaxis until after the Coroner has made findings
6. Department of Health should provide video link facilities and hands-free phone facilities with headsets for remote nursing posts such as Coral Bay where a doctor is not resident and medical support must be provided electronically
7. Medicare Australia or relevant body should revise PBS prescription criteria for Epipens to allow prescription of more than one Epipen at a time and prescription following any anaphylactic reaction (not only where adrenaline was administered or with allergy specialist approval)