Coronial Inquiry

Findings, comments and recommendations of inquest into the death of Wallace Edgar Bryers in Tasmania.

A&AA advises that adrenaline injectors such as EpiPen or Anapen should NOT be kept in car/truck/bus when a person is not in it. Adrenaline injectors should ideally be kept between 15 and 25 degrees Celsius.

Finding into death without inquest of Catherin D’Rozario, aged 17 years in Victoria.

Deceased male, coronial Investigation and finding without inquest, aged 37 in Victoria.

I.M. Aged 9 years Coronial Investigation without inquest in Victoria.

Ruth Hickey Coronial Investigation without inquest in Victoria. Report not released publicly.

Allergy & Anaphylaxis Australia (A&AA) has now been involved in 7 coronial inquests in the last 13 years.

Our involvement is always centred around learning from the sequence of events that led to the death in an effort to prevent another family, school, childcare, camp or sporting club, restaurant/café or healthcare service from living through the very real tragedy of fatality as a result of anaphylaxis.

Death from anaphylaxis is rare but one death is one too many. Deaths from food allergy are almost always preventable. With education and brave families joining us in sharing much needed information, we can continue to improve allergy care together.

Louis Tate was 13 years old when he was admitted to hospital with asthma. His mother clearly told medical staff he had an allergy to cow’s milk, egg, peanuts and tree nuts.  When Louis was admitted to the paediatric unit after 1am  on the 23 October 2015, his mother explained Louis could have Weetbix, soy milk and fruit for breakfast as she knew he would be hungry after not eating dinner the night before. 

Louis started showing signs of an allergic reaction after one spoonful of his breakfast soon after 7.15am. Louis had an anaphylaxis and died several hours later after another allergic response to the anaesthetic he was given when he was placed on life support.

A&AA were invited to put forward a submission answering a very specific question about guidelines available for the emergency management of anaphylaxis in Australia. With the continued generous pro bono support of Clayton Utz, A&AA put forward the submission to Coroner Byrne and he has attached this to his Finding (below). 

The Coroner also asked A&AA to comment on a question about nursing staff and administration of adrenaline autoinjectors in an emergency whilst in a healthcare setting. This letter is also attached to the Finding. While there are no clear recommendations as such, the fact the Coroner included A&AA communication will assist us.

Although there is no recommendation targeting food service in healthcare, we will  continue our work to improve food service throughout Australia, including in hospitals, through the National Allergy Strategy, using documented deficiencies noted by the Coroner.  

We acknowledge the courage of Simon Tate and Gabrielle Catan, Louis’ parents, and his younger brother, and thank them for speaking out to benefit others with food allergy.

A&AA will continue to  advocate for people with allergic disease for the safety and wellbeing of all.

Findings, comments and recommendations of coronial investigation without inquest into the death of Ronak Warty in Victoria

Findings, comments and recommendations of coronial inquest into the death of Jack Irvine in Victoria.

Findings, comments and recommendations of coronial inquest into the death of Raymond Cho in New South Wales.

Coroner urges reform after nut allergy death – ABC News

Findings, comments and recommendations of coronial inquest into the death of Nathan Francis in Victoria.

Findings, comments and recommendations of coronial inquest into the death of Kylie Lynch in Western Australia.

Conclusions from the Victorian Coroner after the inquest into the death of Alex Baptist in Victoria.

Conclusions from the NSW Coroner after the inquest into the death of Hamidur Rahman in New South Wales.

NSW Coroner calls for increased allergy safety.