Overview
- Victorian Coroner David Ryan found Max McKenzie’s best chance of survival required earlier and more frequent adrenaline and rapid intubation on arrival at Box Hill Hospital.
- Paramedics first administered adrenaline about 10 minutes after arriving, despite expert evidence that it should have been given within five minutes under Ambulance Victoria guidance.
- Intubation attempts began roughly 15 minutes after hospital arrival, with delays compounded by the absence of a clear clinical leader during resuscitation, according to the findings and Safer Care Victoria.
- Recommendations include an Ambulance Victoria review of asthma and anaphylaxis guidelines for consistency on adrenaline therapy and emergency driver training for graduate paramedics so senior clinicians can treat patients in the rear.
- Ryan said he was not satisfied the death was definitively preventable in a rare and challenging case; Ambulance Victoria acknowledged the findings and will respond, and Eastern Health expressed condolences.