Anaphylaxis or Asthma? Lessons from Max McKenzie's Inquest

When we teach anaphylaxis, it is easy to make it sound straightforward. Recognise the signs. Give adrenaline. Call 000. Follow the action plan.

Those steps are correct, and they need to stay simple enough to remember under pressure. But the reason behind them matters. Anaphylaxis can move quickly and does not always arrive with the signs people expect. When asthma and food allergy exist together, sudden breathing difficulty can be mistaken for asthma when it may actually be anaphylaxis. That matters because the first treatment is different.

The amended coronial finding into the death of 15-year-old Max Peter McKenzie was published in February 2026. It describes a young person who was intelligent, energetic and deeply loved. It also describes an exceptionally severe allergic reaction, a rapidly changing emergency and the efforts of Max, his family, paramedics and hospital clinicians to save him.

This article is not an attempt to retry the inquest or blame individual clinicians. The coroner noted that a coronial investigation is not about deciding civil or criminal liability or assigning blame, and found that the clinicians caring for Max did their very best in rare and challenging circumstances. The purpose here is to ask what parents, teachers, educators, coaches, employers and first aiders can learn, and how to build a response that still works when the situation is frightening or does not look like the textbook example.

First, Max was a person, not a case study

Max was born on 7 January 2006. The coroner described him as a high school student with a talent for debating, performing and kayaking, remembered for his kindness, curiosity and energy. He was also a son, brother, grandson, friend and classmate.

Max's father, Dr Ben McKenzie, has undertaken extensive advocacy and education about anaphylaxis. The coroner acknowledged that this work, supported by Max's mother Tamara and their family, has contributed significantly to clinical reflection and community learning.

We can learn from Max's story without treating it as dramatic content. We should not imply that every severe allergic reaction will follow the same path, and we should not let the rarity of what happened make us look away from the simple first aid lessons that help in a more typical emergency.

What happened on 6 August 2021

Max had asthma and was allergic to tree nuts and peanuts. He had been prescribed an EpiPen when his food allergies were diagnosed as a toddler.

At about 1:00 pm, Max ate apple crumble at his grandmother's house. Neither Max nor his grandmother knew it contained nuts. At about 1:25 pm his grandmother called his mother. When Tamara arrived, Max was alert. He said he felt sick in the stomach and felt as though he needed Ventolin.

At about 1:40 pm, Max used his EpiPen and Ventolin. Emergency services were called at around 1:50 pm and an Ambulance Victoria crew arrived at 1:57 pm. Max did not initially appear profoundly unwell, although his work of breathing had increased. He told the paramedics he believed he was experiencing anaphylaxis rather than asthma.

His condition then deteriorated dramatically. The paramedics called for MICA backup and gave intramuscular adrenaline and other treatment. Max's breathing became harder, his oxygen level fell, and he later had a seizure, became unconscious and stopped breathing. Ventilating him with a bag-valve mask was difficult because of severe resistance.

He was taken to Box Hill Hospital in a critically unwell condition. Attempts to place a breathing tube through his mouth were unsuccessful, and an emergency surgical airway was established through his neck. His circulation returned and ECMO was started. Max survived the initial event but had a severe brain injury caused by lack of oxygen. He died at the Royal Children's Hospital on 19 August 2021.

The coroner found the cause of death to be cardiorespiratory arrest of unknown cause complicating hypoxic ischaemic encephalopathy in the setting of anaphylaxis. In plain English, Max had a severe anaphylactic event, his body and brain were deprived of oxygen, and he later had a fatal cardiorespiratory arrest.

An exceptionally severe and rare reaction

Please do not read this chronology and assume that adrenaline devices usually fail. The evidence described refractory anaphylaxis, which means the reaction did not respond as expected to the initial treatment. One expert told the inquest that fewer than 2 per cent of people experiencing anaphylaxis fail to respond to one or two doses of adrenaline. Max was in that very small group.

The experts described an extreme, rapidly progressive episode that primarily appeared as life-threatening bronchospasm, where the muscles around the airways tighten so much that moving air into the lungs becomes extraordinarily difficult.

That does not make adrenaline the wrong treatment. It confirms why adrenaline must be given early. Australian guidance is direct: adrenaline is the first-line treatment for anaphylaxis. If there is no response after five minutes, another dose may be given when another device is available. If in doubt, give adrenaline. First aid cannot guarantee an outcome. It can give a person their best available chance while more advanced help is coming.

Why anaphylaxis can look like asthma

Asthma and anaphylaxis can share signs, including difficulty breathing, wheeze, persistent cough, chest tightness, distress and difficulty speaking normally. A person with asthma feels short of breath, so the familiar puffer seems the obvious first step. In an ordinary asthma attack, it may be.

But if the person also has a known allergy and may have been exposed to the allergen, sudden breathing difficulty must raise the possibility of anaphylaxis. The 2026 ASCIA Action Plan states that when someone with known asthma and allergy to food, insects or medication has sudden breathing difficulty after possible allergen exposure, the adrenaline device should be given first, followed by the asthma reliever puffer.

Why? An asthma reliever acts mainly on tightened airway muscles. It does not reverse the whole-body allergic reaction. Anaphylaxis can involve several dangerous processes at once:

• The airway can swell.
• The muscles around the lower airways can tighten.
• Blood vessels can widen and leak fluid, causing blood pressure to fall.
• Oxygen delivery to the brain and other organs can fail.

Adrenaline acts across these problems. The reliever puffer still has a role where asthma symptoms are present. It follows adrenaline. It does not replace it.

No rash does not mean no anaphylaxis

One of the most dangerous myths is that there must be hives, a rash or facial swelling. There may be skin signs, but they are not required. A person may have difficult or noisy breathing, tongue swelling, throat tightness, trouble talking, wheeze, persistent cough, dizziness or collapse without a visible rash.

If someone has memorised only a picture of a swollen face, they may wait for that picture to appear. If they understand that anaphylaxis is a rapidly developing whole-body reaction, they are more likely to recognise the emergency from the breathing or circulation signs in front of them.

Stomach symptoms can be part of the warning

The inquest recorded that Max felt sick in the stomach and described abdominal tightness. After exposure to a likely allergen, abdominal pain or vomiting can be part of an allergic reaction. Stomach symptoms alongside sudden breathing difficulty, throat symptoms, dizziness or collapse should increase concern, not reassure us.

A first aider is not expected to decide whether each symptom comes from asthma, anxiety, allergy or a combination. They are expected to recognise a credible anaphylaxis emergency and take the first correct action.

Anxiety can be a sign of not getting enough air

Max became increasingly anxious as his breathing deteriorated, and at one point expressed fear that he would die. People in severe respiratory distress can look panicked, agitated or uncooperative, and that behaviour can be misread as the cause of the breathing problem.

Do not let the word "anxiety" reduce the urgency of physical danger. Look at the whole person. Are they working hard to breathe? Can they speak normally? Are they pale, blue, confused or drowsy? Has there been possible allergen exposure? Is their condition getting worse despite their usual asthma treatment? Reassure them, but do not reassure yourself into waiting.

What adrenaline actually does

Many people hesitate to use an adrenaline device because they fear the medicine. They worry about a racing heart or shaking, or about misreading the symptoms. That puts the risk in the wrong order.

• It tightens blood vessels, supporting blood pressure and circulation.
• It reduces leakage from blood vessels, helping limit swelling.
• It relaxes muscles around the airways, helping air move more freely.
• It supports the heart during a rapidly deteriorating emergency.

An adrenaline device delivers a measured dose into the outer mid-thigh and is designed for use by members of the community. A fast heartbeat, trembling, paleness or headache can occur. Those effects are not equivalent to the danger of untreated anaphylaxis. ASCIA's advice is that under-treatment of anaphylaxis is more harmful and potentially life-threatening than over-treatment of a mild or moderate allergic reaction. You do not need to wait until the person is unconscious, and you do not need to be completely certain.

The first aid response that needs to become automatic

For suspected anaphylaxis, follow the person's ASCIA Action Plan if available. Otherwise use this sequence:

1. Lay the person flat. Do not allow them to stand or walk. If breathing is difficult, they may sit with their legs outstretched. If unconscious or pregnant, position them as shown on the current ASCIA plan.
2. Give the adrenaline device into the outer mid-thigh without delay, following the instructions for the available device.
3. Call 000 and ask for an ambulance. Say "anaphylaxis" clearly.
4. Give a further adrenaline dose after five minutes if there is no response and another device is available.
5. Give the asthma reliever after adrenaline if the person has asthma and breathing symptoms.
6. Monitor breathing and responsiveness. If the person becomes unresponsive and is not breathing normally, start CPR and use an AED as soon as one is available.

Positioning is regularly underestimated. Anaphylaxis can cause a sudden fall in blood pressure, and standing or walking can make that worse. Keep them in the recommended position and bring the device, phone and help to them.

Tell the call taker that it is suspected anaphylaxis, the person's age and location, the suspected trigger, the signs you can see, when adrenaline was given and how many doses, whether they have asthma, and whether they are conscious and breathing normally. Put the phone on speaker if practical.

Why the five minute check matters

A first dose is not the end of the response. Note the time it was given and watch the person. If there is no response after five minutes and another device is available, current Australian guidance supports giving a second dose. Without someone deliberately watching the clock, five minutes can pass unnoticed.

Allocate roles instead of saying "someone call an ambulance":

• You give the adrenaline device.
• You call 000 and meet the ambulance.
• You bring the second device and the action plan.
• You bring the AED and first aid kit.
• You record times and changes.
• You keep other people back and make space.

When everybody assumes somebody else is doing a task, important actions get delayed. The inquest discussed role clarity and competing priorities in advanced care, and the same human factor applies to a first aid team.

Do not leave the person to manage alone

Max recognised that he was experiencing anaphylaxis and used his own EpiPen. That awareness is significant. It also reminds us that a person having the reaction may be making decisions while frightened, breathless and becoming unwell.

Do not send them to another room to find their device. Do not tell them to walk to the first aid office. Bring help and equipment to them. Emergency plans must work even if the person cannot speak, cannot reach their bag or loses consciousness. Adolescents may minimise symptoms or hope they will settle, so a culture of "tell us early and you will never be in trouble" is a safety measure.

Antihistamines are not the first treatment

Antihistamines may help some skin symptoms in mild allergic reactions. They do not treat the severe breathing or circulation problems of anaphylaxis, and they must not delay adrenaline. Anaphylaxis is not simply a bigger rash. If the person has signs of anaphylaxis, the treatment is adrenaline. Not an antihistamine first. Not a drink of water. Not waiting for a rash. Not driving them to hospital instead of calling an ambulance.

Why asthma and allergy need a joined-up plan

The Safer Care Victoria review considered the combination of asthma and anaphylaxis a high-risk area requiring clearer, more consistent messaging. The coroner recommended that Ambulance Victoria review its separate asthma and anaphylaxis guidelines to ensure consistency in relation to adrenaline therapy.

For families, schools and workplaces, this leads to a practical review:

• Does the person have both an Asthma Action Plan and an ASCIA Action Plan where clinically appropriate?
• Are the plans current and completed by the treating health professional?
• Do the people likely to help know which treatment comes first when the cause is uncertain?
• Are adrenaline devices and asthma relievers immediately accessible, and is more than one adrenaline device available?
• Do carers and staff know anaphylaxis may occur without a rash, and that the person must not stand or walk?
• Has the response been practised, rather than only read?

Plans should be developed and reviewed with the person's doctor or other qualified health professional. First aid training supports the emergency response. It does not replace individual medical management.

The coroner's findings on medical care

The inquest examined whether the care provided by Ambulance Victoria paramedics and Eastern Health clinicians was reasonable and appropriate, and whether prevention opportunities arose. The expert evidence was not identical. Some experts believed earlier interventions might have changed the outcome. Others considered Max's reaction so severe that a poor outcome may have occurred even with ideal treatment.

The coroner found that Max's deteriorating condition required earlier and more frequent adrenaline while he was with paramedics, consistent with the applicable Ambulance Victoria guideline. The coroner also recognised that paramedics were managing a rapidly evolving situation with limited resources, was not satisfied that oxygen was unreasonably delayed, was satisfied the paramedics reasonably managed competing treatment priorities while arranging urgent transport, and found that prioritising transport over a high-risk intubation before the short journey to hospital was reasonable.

At Box Hill Hospital, the first attempt to intubate Max occurred about 15 minutes after arrival. The coroner found that reasonable care required an earlier attempt to establish a secure airway.

The coroner did not find that Max's death was proven preventable. Earlier adrenaline and an earlier secure airway would have given Max the best opportunity for survival, but his refractory anaphylaxis was exceptionally severe, and even with earlier action he may still have suffered cardiac arrest, brain injury or death. We can identify opportunities for better care without pretending certainty about an outcome that cannot be known.

The coroner's recommendations

• Ambulance Victoria should review its separate guidelines for treating asthma and anaphylaxis to ensure consistency concerning adrenaline therapy.
• Ambulance Victoria should ensure graduate paramedics receive emergency driving training during induction before beginning on-road clinical practice.

The second recommendation arose from a staffing problem during Max's transport. The graduate paramedic was not qualified to drive under emergency conditions, so the experienced clinical instructor drove rather than both senior clinicians being available in the back of the ambulance. These are health-system matters, but the lesson applies to every organisation: equipment matters, training matters, communication matters, and a plan must work under real pressure, not only on paper.

What schools and childcare services should check

• Can every relevant staff member recognise anaphylaxis without skin symptoms?
• Can relief, administration, grounds and casual staff locate the devices immediately?
• Are devices taken to the oval, playground, excursion, bus, camp and sporting event?
• Can staff use each type of device kept onsite?
• Is a current individual action plan available without searching a locked office?
• Is a general-use adrenaline device available in line with your organisation's requirements and risk assessment?
• Does someone check expiry dates and device condition?
• Can staff explain that adrenaline comes before the asthma reliever when anaphylaxis is suspected?

A child should never have to walk to the sick bay during suspected anaphylaxis. Treatment must come to the child. Practice scenarios should include ambiguity: a sudden cough and wheeze after food exposure, no rash, a device inside a backpack, a locked gate and a second dose that may be needed. That is where the gaps become visible.

What workplaces, clubs and event organisers should check

Anaphylaxis is not only a school issue. Adults can react at workplaces, restaurants, sporting clubs, community events, remote sites and while travelling. Know where adrenaline devices are, whether a general-use device suits your site's risk profile, who is trained to use them, how 000 will be contacted when reception is poor, who will meet and direct the ambulance, where the AED is, and how treatment times will be recorded.

For regional and remote workplaces, response time changes the planning. That means speaking with appropriate health professionals, carrying suitable equipment, checking communication coverage, training enough people across every shift and having a clear emergency access plan.

What people at risk and their families can do

Responsibility should never sit entirely with the person at risk, especially a child or teenager. Still, preparation makes it easier for others to help. With the treating health professional:

• Keep the ASCIA Action Plan current.
• Carry the prescribed adrenaline device and know how to use it, and carry more than one where advised.
• Check expiry dates and store devices following manufacturer advice.
• Make sure family, friends, colleagues, teachers and coaches know where the device is.
• Review asthma control regularly.

Owning a device is not the same as being ready. In an emergency, people freeze, forget which end goes against the leg, or wait for permission. Regular practice with trainer devices turns knowledge into action.

What good first aid training should change

A first aid course should not leave people able to pass a quiz but afraid to touch the device. People need to understand why adrenaline is first-line, why a reliever is not a substitute, why a rash is not required, why the person should not stand or walk, why a second dose may be needed after five minutes, why 000 must be called even if the person improves, and why CPR starts if the person becomes unresponsive and is not breathing normally.

Then they need to practise: hold trainer devices, make a mock 000 call, allocate roles and respond to a scenario that changes. Autopilot is not mindless action. It is a well-understood sequence practised enough that stress does not erase it.

A simple scenario to test your response

A 16-year-old with known asthma and a cashew allergy eats a dessert at a community event. Ten minutes later they start coughing and say their chest feels tight. There is no rash. They use their reliever puffer, but their breathing gets harder. They look frightened and say they feel sick.

Do not wait for facial swelling. Do not decide it is "just asthma" because they are wheezing. Lay them flat, or let them sit with legs outstretched if breathing is difficult. Give the adrenaline device first. Call 000. Give the asthma reliever after adrenaline. Note the time and prepare the second device. If symptoms have not responded after five minutes, give the second dose. If they become unresponsive and are not breathing normally, start CPR and use an AED.

Frequently asked questions

The lesson is not fear. It is readiness.

Max's story is confronting because he had a known allergy, recognised the reaction and used his EpiPen, yet the reaction continued to progress. Rare, extreme anaphylaxis exists, and even skilled teams can face an extraordinarily difficult emergency. But fear is not the useful takeaway.

The useful takeaway is that anaphylaxis deserves decisive early action. Breathing symptoms may be anaphylaxis even without a rash. In someone with asthma and a relevant allergy, adrenaline comes before the asthma reliever when anaphylaxis is suspected. The person should not stand or walk. A second dose may be needed after five minutes. Call 000. Start CPR if they become unresponsive and are not breathing normally.

Review the plans. Check the devices. Practise the sequence. Teach the reason. If anaphylaxis happens, give adrenaline and call 000.

Sources and further information

Coroners Court of Victoria, Inquest into the Death of Max Peter McKenzie, Finding into Death Following Inquest, delivered 5 February 2026 and amended 20 February 2026.
ASCIA First Aid Plan for Anaphylaxis
ASCIA Action Plans for Anaphylaxis
ANZCOR Guideline 9.2.7: First Aid Management of Anaphylaxis
ANZCOR Guideline 9.2.5: First Aid for Asthma
Healthdirect: Anaphylaxis

This article provides general first aid education and is not individual medical advice. People at risk of anaphylaxis or asthma should follow their personal action plans and seek advice from their treating health professional.