Finding into death of Max Peter McKenzie

15y · Male·Cardiorespiratory arrest of unknown aetiology complicating hypoxic ischaemic encephalopathy in the setting of anaphylaxis

Max McKenzie, a 15-year-old with asthma and food allergies, died from cardiorespiratory arrest complicating hypoxic ischaemic encephalopathy after severe refractory anaphylaxis. After eating apple crumble containing nuts, he self-administered an EpiPen. Ambulance paramedics administered adrenaline but Max deteriorated rapidly. At hospital, emergency physicians delayed intubation for 15 minutes despite critical hypoxia, attempting to stabilise him first. A surgical airway was eventually established via cricothyroidotomy. The coroner found that while early adrenaline dosing and earlier airway establishment would have given Max the best chance of survival, his death was not preventable—he had refractory anaphylaxis with significant mortality risk even with optimal treatment. Key failures: delayed first adrenaline dose by paramedics, lack of IV adrenaline administration earlier, and delayed intubation decision by ED physicians despite obvious severe hypoxia.