‘He had the world at his feet’: Coroner finds ‘missed opportunities’ in teen’s anaphylactic death

Harry Tsindos hunched over in his chair and wept as details of his teenage son’s final moments were read out in the Victorian Coroner’s Court.

In his hands he held a wooden stick figure, a present from his son James, who made the ornament when he was in grade 3. He found the gift by chance in the back seat of his car this week.

“Dad, I love you so much and happy Father’s Day,” a handwritten note scrawled on it read. “I’ll never let you go.”

On Friday, coroner Sarah Gebert ruled there had been several missed opportunities in the year 12 student’s medical care after he suffered a severe anaphylactic reaction to a burrito bowl and was rushed to hospital on May 27, 2021.

In the corner of the packed courtroom sat a smiling photo of 17-year-old James, dressed in his Brighton Grammar uniform, a “piano prodigy”, who was intelligent, kind, funny and adored by his family.

His mother, Venetia, sat in the front row and wiped away tears, her fingernails painted black and white like the keys of a piano in honour of the son who had filled their home with serene music.

The meal, which James ordered from a vegan restaurant via now-defunct food delivery app Deliveroo, contained a cashew nut sauce.

James, who had history of allergic rhinitis and asthma, noticed his lip swelling, tingling in his throat and abdominal pain after eating part of the burrito bowl.

His dad called an ambulance and James received two doses of adrenaline from paramedics five minutes apart. His condition appeared to improve, but the inquest heard that James developed a wheeze on the way to Holmesglen Private Hospital.

The teenager told healthcare workers at the hospital he was struggling to breathe, and he wanted his mum. Seconds later, he lost consciousness.

Gebert said that James’ wheeze warranted an emergency category 2 response from the hospital, triggering urgent treatment within 10 minutes.

Instead, staff had triaged him as category 3, requiring treatment within 30 minutes.

Expert witnesses Associate Professor Warwick Butt, an intensive care consultant and globally decorated clinician, told an inquest James’ wheezing and his use of an asthma puffer 15 times at the hospital should have been a red flag to immediately escalate his care.

“His condition was likely to become very severe, very quickly. He needed immediate treatment,” Butt said.

However, Gebert noted there has been a failure by the hospital staff to recognise the severity of James’ wheeze, which should have been treated as if it were secondary anaphylaxis: a dangerous recurrence of severe, life-threatening allergic symptoms that can happen after the initial reaction.

At 4.10pm, James’ condition deteriorated rapidly, and he was administered a third dose of adrenaline.

He was transferred to the resuscitation ward and quickly went into cardiac arrest.

Gebert agreed with an expert medical panel who found that earlier administration of that third shot of adrenaline, by roughly 10 to 15 minutes, may have significantly improved James’ chances, but may not have guaranteed his survival.

She made eight recommendations including that the Department of Health update its guidelines around anaphylaxis management for young people who also suffer from asthma.

“The loss of James to his family has been shattering, and I do not have the words which could even come close to encapsulating that loss,” Gebert said.

“It is apparent that his death occurred at a time when he was excitedly contemplating his future beyond school. He had the world at his feet.”

The coroner called for Safer Care Victoria to develop a statewide approach to the treatment of anaphylaxis presentations in emergency departments and increase awareness of recurrent attacks.

She said the state’s health department should also require best practice guidelines, developed by the National Allergy Council and the Allergy and Anaphylaxis, to be used for online food ordering to reduce the risk of allergic reactions from inadvertent exposure.

Outside court, Harry clutched a photo of his son while the family’s lawyer, Shari Liby, from Slater and Gordon, read out a statement on their behalf.

“James lit up our lives and those of everyone around him, and without him things are dark,” they said.

“What happened to James is a tragedy that has shattered our family. We, like the coroner, hope that the terrible circumstances of James’ death can be used to keep other patients safe in the future.

“While our family home is no longer filled with the sound of James at the piano, we do feel some gratitude to know that his death has not been in vain.”

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