James Tsindos Coronial Inquest: Key Anaphylaxis Learnings

By Britt Brennan, REACHAU | Updated 16 October 2026

What happened

James was a 17-year-old Year 12 student with a tree nut allergy, asthma and a history of hay fever. He had not been diagnosed with anaphylaxis and had not been prescribed an adrenaline autoinjector. On 27 May 2021 he ordered a vegan burrito bowl online. The bowl contained a nacho cashew cheese sauce. The delivery app description listed 'nacho cashew cheese', but the ingredient list shown while browsing was cut short, and the full list only appeared after the meal was selected.

His father called triple zero. Paramedics gave two doses of adrenaline and took him to Holmesglen Private Hospital. He appeared well at first, but his condition worsened soon after arrival and he went into cardiac arrest. He was transferred to the Alfred Hospital, where he was declared brain dead and died on 29 May 2021. ECMO support was withdrawn on 1 June 2021.

This article reports what the coroner found. It is not a substitute for the full written finding.

What you will learn

• Why wheezing after an allergic reaction needs careful attention, even in someone with asthma
• What the coroner said about adrenaline timing
• What the finding says about handover
• Why vegan food is not automatically allergen-safe
• What first aiders can do differently

1. When wheeze is not just asthma

One of the strongest themes in the findings was how asthma can complicate recognition of anaphylaxis. After James arrived at hospital he developed a new wheeze. It was passed on at handover and treated with Ventolin, rather than being recognised as a possible return of anaphylaxis needing further adrenaline.

The wheeze was handed over at about 3.52 to 3.55pm. Intramuscular adrenaline was likely not given until about 4.10pm, by which time he was deteriorating quickly. The coroner found that his chances of survival would no doubt have been greater with earlier adrenaline and earlier recognition that he was at risk of severe recurrent anaphylaxis. The expert panel could not agree how much difference it would have made, and the coroner could not say it would have saved his life. The coroner also noted the speed of his deterioration, an RSV infection and poorly controlled asthma.

The ASCIA Action Plan for Anaphylaxis tells responders to give adrenaline first, then asthma reliever medication for a person known to have asthma. Understanding that order, and acting on it, is one of the most important things a first aider can take from this case. We teach it in HLTAID011 Provide First Aid and in HLTAID014 Provide Advanced First Aid. See also why adrenaline comes before the inhaler.

2. Handover

The finding spent a lot of time on exactly when the paramedic handover happened and what was said and heard. James was stable at handover, with a mild ongoing wheeze, and the coroner noted there was no hint that within about 20 minutes he would be unconscious. The coroner also found the paramedics' decision not to give a third dose of adrenaline was reasonable, based on guidelines and how he looked at the time.

Recommendation 4 asks Ambulance Victoria to highlight its handover work instruction, which includes agreeing with the emergency department clinician that the ambulance handover is complete. Clear, complete communication matters in any emergency. In anaphylaxis, where a person can deteriorate quickly, it matters even more.

Whenever you hand over a patient to paramedics or hospital staff, say clearly what happened, what treatment was given and when, and any new symptoms such as wheeze or difficulty breathing.

3. Symptoms can return after improving

After adrenaline, a person can appear to improve and then get worse again. Symptoms can return, sometimes hours later, and more doses may be needed. This is called biphasic anaphylaxis. It is why anyone who has had anaphylaxis needs urgent medical assessment and observation, and why you should always call 000. Follow the advice of paramedics and the treating team.

Improvement does not mean the danger has passed.

4. The vegan trap: hidden allergens in "safe" food

Many people assume vegan food is allergen-friendly. It often is not. Cashews are widely used in vegan cooking to replace dairy in sauces, creams, cheeses and desserts.

The coroner noted that James was very careful with his food choices. She suspected he presumed a burrito bowl with nacho sauce would be made only of cheese, and that the restaurant was new to him and served vegan food, which regularly contains nuts instead of dairy products.

The coroner made several recommendations to the Department of Health. They include allergen training for food safety supervisors, following best practice guidelines for online food ordering, and action on consumer education and the labelling of plant-based or vegan food substitutes.

For anyone with a severe allergy, check full ingredient details with the venue, not just the headline menu description.

5. The bigger lesson

James's death was not explained by one single mistake. Real emergencies rarely are. Anaphylaxis management is about the full picture:

• Recognising symptoms early, including in someone with asthma
• Understanding that asthma and anaphylaxis can occur together
• Giving adrenaline without delay, as the ASCIA Action Plan advises
• Calling 000 and making sure the person is medically assessed, even if they seem to have recovered
• Clear, complete communication at handover
• Allergen awareness in hospitality, food delivery and food service
• Broader first aid education, so bystanders know what to do in the first minutes

Other recommendations asked Ambulance Victoria to consider whether paramedics should carry EpiPens, and Safer Care Victoria to consider a statewide approach to treating anaphylaxis in emergency departments, including awareness of biphasic reactions.

6. What first aid training should prepare people to do

For employers, school staff, food service teams and anyone responsible for others, this case shows why anaphylaxis training is more than a box to tick. People need to understand:

• How to recognise anaphylaxis, including when there is no rash
• Why breathing symptoms may be mistaken for asthma
• Why adrenaline is given first when anaphylaxis is suspected
• Why the person should lie flat, unless breathing is difficult, and must not stand or walk
• Why an ambulance must always be called
• Why improvement after adrenaline does not mean the danger has passed

In an emergency, the most important skill is staying calm and taking the first correct action. Good training gives you an understanding of what is happening in the body, why the treatment works and the confidence to act without wasting critical time. You can read more in our guides to the most common anaphylaxis first aid mistakes, why practising your anaphylaxis response matters and the adrenaline devices available in Australia.

Frequently asked questions

What caused James Tsindos's death?

The coroner found the cause of death was hypoxic ischaemic encephalopathy, which is brain injury from a lack of oxygen, complicating anaphylaxis.

Why does asthma complicate anaphylaxis?

Wheezing can look like asthma alone and be treated that way, which can delay adrenaline. In a person with asthma and a likely allergen exposure, wheeze may be a sign of worsening anaphylaxis.

What is biphasic anaphylaxis?

It is when symptoms return after improving, sometimes hours later, without further exposure to the allergen. Anyone treated for anaphylaxis needs medical assessment and observation.

Is adrenaline more important than Ventolin in anaphylaxis?

The ASCIA Action Plan advises giving adrenaline first, then asthma reliever medication for a person known to have asthma.

Can vegan food contain hidden nut allergens?

Yes. Cashews and other tree nuts are commonly used in vegan cooking. Confirm full ingredient details with staff, and check beyond the headline menu description when ordering through apps.

Why I support Anaphylaxis Awareness

I speak about cases like this in training because people remember stories far more than slides. Not to frighten people, but to prepare them. Calm, informed action in the first minutes of a severe allergic reaction can make a real difference. No family should have to experience the loss the Tsindos family has endured.

If you want to support awareness, education and advocacy for people with severe allergies, you can donate to the Anaphylaxis Awareness fundraiser.

This article provides general first aid education and is not individual medical advice. In an emergency, call 000. Follow the person's ASCIA Action Plan and current ASCIA and ANZCOR guidance.