00:05A year 12 student and piano prodigy, described as being in the happiest time in his life.
00:12He did everything. He was a triple threat.
00:16In an emotional hearing attended by family and friends, a tearful Victorian coroner handed down the findings of an inquest
00:23into James Sindos' tragic death at age 17.
00:26James had a nut allergy and asthma, but wasn't diagnosed with anaphylaxis.
00:31The coroner found James experienced a severe allergic reaction after consuming a vegan burrito bowl he'd ordered online.
00:39The meal was labelled as containing cashew cheese, but it was suspected he assumed it was regular cheese.
00:47James was rushed to Melbourne's Holmes Glen Hospital via ambulance and initially responded well to two doses of adrenaline.
00:55But soon after, he had trouble breathing and went into cardiac arrest.
00:59He was transferred to the Alfred Hospital, where he later died.
01:03The coroner was unable to determine if improvements to James' medical care could have saved his life.
01:10But she identified two missed opportunities, which meant an urgent third dose of adrenaline was delayed.
01:17James' chances of survival would no doubt have been greater had he been given adrenaline sooner, coroner Sarah Gerbert said.
01:25The family welcomed the coroner's eight recommendations, among them a suggestion for improved consumer education around vegan food substitutes, as
01:35well as the consideration of new medical guidelines for asthma and anaphylaxis patients.
01:40We will have to live with this forever. However, we, like the coroner, hope that the terrible circumstances of James'
01:49death can be used to keep other patients safe in the future.
01:52He's a special boy, and you can't just let his passing, you can't let him be fine.
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