A coroner cannot determine whether a 17-year-old boy who suffered a severe allergic reaction to a home-delivered meal would have survived if he was given adrenaline sooner.
James Tsindos experienced anaphylaxis on the afternoon of May 27, 2021, after eating a burrito bowl ordered off the now-defunct Deliveroo app.
The meal contained a sauce made from cashews and James began experiencing allergy symptoms, including swollen lips, nausea, tingling in the throat and abdominal cramps.
His father called an ambulance and paramedics arrived at their Brighton home in Melbourne's southeast about 2.50pm.
James received two doses of adrenaline five minutes apart and he was transferred to the nearby Holmesglen Private Hospital as a precaution.
As he arrived at the hospital about 3.44pm, he told the paramedics he was "wheezy" and he used his asthma puffer.
At 4.10pm, James' condition deteriorated and he was administered a third dose of adrenaline but he still had trouble breathing.
He was transferred to the resuscitation ward and within a minute became unresponsive before entering cardiac arrest.
Doctors and nurses tried to resuscitate James and he was transferred to The Alfred but never recovered.
His life support was turned off on May 29.
An inquest into James' death was held in October 2024 and coroner Sarah Gebert on Friday delivered her findings.
She determined while James might have survived if he was administered the third dose of adrenaline sooner, she could not be certain.
Ms Gerbert noted a panel of experts had reviewed the case and had differing opinions on James' ultimate prognosis.
The coroner said she could not side with a particular expert on whether James' death was preventable.
"I express my regret to the family that I am unable to do so," she said.
Ms Gerbert made eight recommendations, including that the Department of Health update its guidelines around anaphylaxis management.
