Finding into death of Nathan Fazal Francis

13y · Male·anaphylaxis from ingested peanuts

Nathan Francis, a 13-year-old boy with known severe peanut allergy and asthma, died from anaphylaxis after ingesting beef satay containing peanuts during an Army Cadet camp in the Wombat State Forest. The death resulted from multiple systemic failures at Scotch College: inadequate cross-referencing of medical information (including known peanut allergy) against food supply contents; random distribution of combat ration packs without allergy consideration; failure of staff to familiarise themselves with EpiPen administration despite first aid training; and a 10-minute delay before the first EpiPen was administered. While emergency medical response was appropriate and Dr W. provided excellent resuscitation efforts, the remoteness of the location and Nathan's unstable asthma made recovery unlikely once respiratory arrest occurred. The death was preventable through better care and attention to medical information prior to camp.