‘Max should still be with us’: Teenager who died of anaphylaxis should have been treated sooner, coroner finds

A teenager who died following an anaphylactic reaction should have received life-saving treatment earlier, the coroner’s count has found.

The devastated father of 15-year-old Melbourne teenager Max McKenzie, who had severe nut allergy and died after accidentally consuming walnuts in 2021, said no parent should ever be put in the position he was.

When Max’s father, experienced emergency doctor Ben McKenzie, arrived at Box Hill Hospital, he tried to resuscitate his own dying son.

“I should never have had the opportunity to participate in Max’s resuscitation because it should have been done before I got there,” he said outside the Victorian Coroner’s Court.

“As an emergency physician, when you see someone who is arriving who can’t breathe, who is unconscious, they need to be put on a breathing machine and intubated and put on life support immediately.

“Box Hill [Hospital] didn’t do that. Max should still be with us if he had have been intubated on arrival.”

On Thursday, Victorian Coroner David Ryan, who oversaw an inquest into Max’s death, handed down his report, finding the teenage boy’s best chance of survival upon arrival at the hospital required a mechanical airway to be established immediately.

He said while he understood staff had tried to stabilise Max and were concerned about the chance he could go into cardiac arrest, the risks associated with intubation were outweighed by the dangers of delaying the potentially life-saving procedure.

He said immediate intubation was the only treatment option that could have saved Max given his perilous condition.

“Max’s condition required more immediate action by the suitably qualified and experienced clinicians already present in the ED,” Ryan said in his findings.

The coroner also agreed with the findings of Safer Care Victoria, which found there were delays in identifying a clear clinical leader for Max’s resuscitation at the hospital, further hindering his intubation during a crucial time.

Ben McKenize said staff at Box Hill Hospital took 15 minutes before staff attempted to try to intubate Max, and he helped to perform a tracheostomy on his teenage son.

The teenager had carefully managed his anaphylaxis for years before he ate an apple crumble, which he was unaware contained walnuts, at his grandmother’s house on August 6, 2021.

Before paramedics arrived, Max, who also had asthma, had used his EpiPen and Ventolin after having the anaphylactic reaction that would end his life.

The first ambulance arrived just before 2pm. Advanced life support paramedics found Max struggling to breathe.

Within 10 minutes, his breathing became worse and a MICA intensive care ambulance was requested.

Ryan agreed with evidence given to the inquest by medical experts that Max should have been given a shot of adrenaline within five minutes of the first paramedics arriving, in line with Ambulance Victoria guidelines.

The first dose of adrenaline was given to Max about 10 minutes after paramedics arrived.

“Max’s deteriorating condition required the administration of earlier and more frequent adrenaline,” Ryan said.

“However, I acknowledge that the paramedics were managing a rapidly evolving and distressing situation.”

The inquest previously heard Max was placed on a nebuliser, which was initially not working properly.

The inquest also heard that a graduate paramedic who was on duty had not been trained to drive an ambulance.

This meant a more experienced and skilled paramedic drove the emergency vehicle, while the graduate paramedic assisted the MICA paramedic in treating Max in the back of the ambulance.

Max suffered a seizure in the ambulance and was unresponsive when he arrived at Box Hill Hospital. Six minutes after he arrived, Max’s heart rate slowed and he was given CPR.

On August 19, Max experienced a sudden cardiac arrest and died.

Following Max’s death, Ryan called for Ambulance Victoria to ensure graduate paramedics undergo emergency driving training during their induction period before entering on-road clinical practice in line with other states across Australia.

In harrowing evidence to the inquest, Max’s mother, Tamara, said when her son screamed that he was going to die, she reassured him that he was not.

It is a moment that still haunts her. “I now must live with knowing I got that so wrong,” she said.

Outside court, his family described him as a “champion” who had big dreams, loved life and was a vibrant, determined, curious, intelligent and loving boy deeply missed by his parents, sisters Ella and Lucy and younger brother Charlie.

He loved swimming, skiing, performing arts, debating and kayaking.

“Max was let down so many ways, in so many points in time, from the minute healthcare came to him,” Tamara McKenzie said.

“All along the way, Eastern Health has told us that Max’s care was best practice and best care. Today the coroner has told us it wasn’t, and we’ve been fighting to hear that.”

Since his death, his parents have advocated tirelessly for better anaphylaxis management and increased allergy awareness aiming to improve care for other young people with allergies.

Ryan said he was not satisfied that Max’s death was preventable as a result of the treatment by healthcare workers, describing the severe episode of refractory anaphylaxis the teenager experienced and the circumstances of his resuscitation as “rare and incredibly challenging”.

“I am not able to be comfortably satisfied that it was preventable,” he said. “It is possible that Max’s experience of refractory anaphylaxis was one of the rare cases that may have resulted in a poor outcome even with the best treatment.”

An Eastern Health spokesperson said: “Eastern Health again extend our deepest sympathies to the McKenzie family. We acknowledge the finding handed down by Coroner Ryan this afternoon and make no further comment at this time.”

A spokesperson for Ambulance Victoria said: “Ambulance Victoria’s deepest sympathies and thoughts remain with the McKenzie family for their devastating loss. Ambulance Victoria acknowledges the Coroner’s findings delivered on 5 February 2026 and will respond to the Coroner’s recommendations.”

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