BOY, 15, WHO DIED AFTER EATING A SLICE OF APPLE CRUMBLE WAS 'ROBBED' OF HIS BEST CHANCE OF SURVIVAL

The death of a teenage boy who suffered a severe allergic reaction after eating a slice of apple crumble has been ruled as possibly preventable by a coroner.

Melbourne boy Max McKenzie, 15, was at his grandmother's home when he suffered a fatal anaphylactic reaction in August 2023. 

Max, who was severely allergic to nuts, had no idea the apple crumble contained traces of walnuts - nor did his grandmother.

He used his EpiPen and Ventolin - as he also suffered from asthma - before he was rushed to hospital as his condition rapidly deteriorated. He died on August 19. 

Victorian coroner David Ryan held an inquest into Max's death and the interventions given to him in the lead-up and, on Thursday found several steps were missed by medical professionals. 

These included paramedics failing to give him adrenaline at the earliest opportunity, and medical staff at Eastern Health's Box Hill Hospital not intubating him soon enough. 

'I am satisfied that… he required the administration of earlier and more adrenaline while being treated by Ambulance Victoria paramedics, and more critically, the earlier establishment of a secure airway by Eastern Health clinicians,' he said, the Herald Sun reports.

'This would have given him the best opportunity for survival.'

'However, I am not satisfied that his death was preventable as a result of the treatment by paramedics and clinicians on that day,' the coroner said.

'It may have been, but I am not able to be comfortably satisfied that it was preventable.'

Mr Ryan said the circumstances were 'rare and incredibly challenging' for all medical professionals.

He found a graduate paramedic should have driven the ambulance with lights and sirens to hospital, allowing her instructor and an intensive care paramedic to care for Max in the back.

The coroner recommended Ambulance Victoria review its guidelines for the treatment of patients with asthma and anaphylaxis, to ensure consistency in the administration of adrenaline.

He also recommended graduate paramedics undergo emergency driving training before they hit the road, to ensure more experienced workers were in the back treating the patient.

Outside the court, Max's parents expressed their concern over missed opportunities to save their son's life.

'It's been four-and-a-half years to get to these coronial findings, it's been a long journey,' his father - and emergency physician - Dr Ben McKenzie said.

'While not every aspect or concern we have about Max's care was able to be addressed today, the coroner found that Max should've got more adrenaline from Ambulance Victoria and he should've been intubated on arrival at Eastern Health Hospital.

'Those two things didn't happen, and they robbed Max of his best chance of survival.

'Max should not have died.'

Dr McKenzie gave CPR to his son after he was taken to hospital on August 6, which he said should never have happened.

'I should never have had the opportunity to participate in Max's resuscitation because it should have been done before I got there and I think the coroner has highlighted that today,' he said.

Max's mother Tamara said the hospital told them their care of the 15-year-old was 'best practice and today the coroner has told us it wasn't', as she asked for a 'heartfelt apology' from Eastern Health.

'Max was let down in so many ways, at so many points in time, and the coroner has found two points where Max's care was not appropriate and not OK,' she said.

Eastern Health and Ambulance Victoria extended their 'deepest sympathies' to the McKenzie family.

A spokesperson for Ambulance Victoria told the Daily Mail in a statement that it planned to respond to the coroner's recommendations.

'Ambulance Victoria's deepest sympathies and thoughts remain with the McKenzie family for their devastating loss,' they said.

'Ambulance Victoria takes very seriously its commitment to patient safety and strives to continuously improve the care and services it provides to the community.

'Ambulance Victoria acknowledges the Coroner's findings delivered on 5 February 2026 and will respond to the Coroner's recommendations.'

A spokesperson for Eastern Health added: '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.'

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2026-02-05T20:57:29Z