An inquest has heard that a 19-minute delay in attempting to intubate a critically ill teenager at Box Hill Hospital may have cost him his life, with one expert telling the court the missed ten-minute window “really sealed his fate”.
Max McKenzie, a beloved 15-year-old, died in August 2021, nearly two weeks after suffering a severe brain injury triggered by an anaphylactic reaction when he accidentally consumed food containing nuts. He arrived at Box Hill Hospital unconscious, not breathing, and on the verge of cardiac arrest.
The Coroners Court was told that, despite the urgency of his condition, medical staff did not attempt to intubate for 19 minutes. A panel of specialists testified that a particularly critical ten-minute period before cardiac arrest was the time when decisive action should have been taken.
Dr Andrew Numa, Director of Intensive Care at Sydney Children’s Hospital, said the delay was catastrophic.
“This is a patient dying in front of your eyes. The time to act is now,” he told the court. He stressed that if Max had been intubated within five minutes of arrival, “it’s likely he would have survived”, though perhaps with a non-fatal brain injury.
Other experts offered differing views. Associate Professor David Armstrong, Head of Respiratory Medicine at Monash Children’s Hospital, said Max’s reaction was so severe that death may not have been preventable despite earlier intervention. But the panel agreed that clear leadership was lacking in the emergency response.
“Nobody was steering the ship,” Dr Numa said, noting the absence of an appointed team leader.
The inquest also heard evidence that paramedics should have administered adrenaline sooner, given additional doses, and called for MICA back-up earlier. Dr Stephen Rashford, Queensland Ambulance Medical Director, said a “couple of minutes could have been shaved off”, but added that paramedics were operating in a difficult real-world environment and he did not view that as the primary issue.
Max’s parents, Dr Ben McKenzie—an emergency physician who helped resuscitate his own son upon arrival—and Tamara McKenzie, said the testimony confirmed long-held concerns about their son’s treatment.
“When Max first died, Eastern Health told us his care was best practice,” Dr McKenzie said outside court. “We’ve heard today that it wasn’t.”
The McKenzie family have spent four years seeking answers over Max’s death, which prompted a broader discussion about emergency response standards in anaphylaxis cases.
“We are heartbroken,” Tamara McKenzie said, “but grateful Max’s voice is being heard. Max should be here, and this process is really important.”
Experts acknowledged the emergency was chaotic and emotionally charged, but said protocols for rapid intubation should still have been clear. The inquest continues, with further examination of systemic issues and staff decisions on the night of Max’s collapse.
Max is remembered as a kind and energetic son, brother and friend who loved kayaking, the performing arts, technology, and spending time with his family.
