Emergency specialist Ben McKenzie helped resuscitate his own child after arriving at Box Hill Hospital to see his son Max – rushed to emergency after an allergic reaction to nuts – in August 2021.

Dr McKenzie said Max, who was just 15, should be alive, but emergency staff waited more than 15 minutes to intubate the dying teenager – and then failed – forcing him to step in.

“No one should have to ­resuscitate their own child in someone else’s hospital, it’s just … it’s not right,” he said.

Max’s circulation returned immediately but brain cell death begins after just four minutes without oxygen and Max had waited more than 20 for “basic emergency department resuscitation”.

He died from brain damage complications 13 days later at the Royal Children’s Hospital.

But Box Hill Hospital failed to properly report Max’s death and, after investigating itself, ruled Max’s care was “best practice” in a report it refused to give his parents.

In the ambulance that day – just minutes before losing consciousness – Max yelled he was going to die.

Tamara McKenzie did not know it at the time, but she had just heard her son’s last words.

Ms McKenzie and her husband have spent two and a half years fighting for accountability and answers, and are increasingly alarmed by Eastern Health’s denials and insensitive interactions.

They fear little has changed and said chief executive David Plunkett and chief medical officer Alison Dwyer told them late last year that a similar incident still would not be reported automatically as a sentinel event.

Ms McKenzie said they had hoped to work with Eastern Health “to make sure that no child would die in similar circumstances” and were not seeking blame.

“We don’t believe that another death similar to Max’s won’t occur again,” she said.

But they also fear government bodies lack real power to properly investigate deaths and critical safety issues at Victorian hospitals, and want the system overhauled.

Hundreds of pages of emails and meeting transcripts show the many organisations Max’s parents approached for help after Eastern Health repeatedly ignored questions and ­delayed meetings.

Sentinel events – health care’s most serious adverse incidents – should be reported to Safer Care Victoria within three days, but it did not do so until Dr McKenzie reported his own son’s death in late December 2021.

Ms McKenzie said she did not think life could get worse after Max’s death but the hospital made it “so much harder”, treating them “like a legal issue rather than a grieving family”.

“No family should have to be the ones to report their child’s death,” she said.

She said Professor Plunkett’s emails caused her “so much distress, and many sleepless nights”.

Hospital executives told Max’s parents the review found his death was not preventable right before Christmas and, for more than 18 months, refused to tell them the name of their son’s anaesthetist.

Dr McKenzie said they wanted to understand what happened and protect others, but neither Professor Plunkett nor the hospital board had been “interested” and SCV’s unpublished review failed to “properly identify what went wrong”.

He said SCV was designed to help services “investigate their own actions” as opposed to running independent probes and, based on his professional experiences, was powerless to enforce recommendations.

“Sentinel event recommendations are frequently viewed as tick box exercises,” he said.

“There is no fear of repercussions.”

Max’s parents tried to warn Health Minister Mary-Anne Thomas about the executive’s comments on reporting sentinel events, but Ms Thomas said she could not comment on a “private meeting” and referred to SCV’s work.

Ms McKenzie said they had not wanted to speak out but had no option and were in a “unique position” because of her husband’s work.

“How can there be no repercussions for Eastern Health not reporting Max’s death to Safer Care Victoria, or not undertaking an adequate clinical review?” she said.

Victoria’s peak child mortality committee later reviewed several similar deaths and their January 2024 report confirmed patients like Max – cited as a case study – should be intubated within four minutes.

Max’s death has been referred to the coroner, who is already investigating a Melbourne hospital’s care of James Tsindos, 17, who died after an anaphylactic reaction in June 2021.

Dr McKenzie, at the time a senior emergency physician and now completing a PhD in allergy research, will always wonder if – instead of treating another critically ill Victorian – he’d been able to get to Box Hill earlier.

“Max did everything right. He took his own EpiPen, he called for help, but he still died,” he said.

“Being in the eastern suburbs was more dangerous than being in the Sahara desert for Max.”

An Eastern Health spokesman said it was co-operating with the coronial process.

He did not directly answer when asked if he was confident that no one else would die in similar circumstances, saying the organisation would not comment further on a matter before the coroner.

A government spokeswoman also cited the coroner’s case to decline further questions, ­including whether the Health Minister had confidence in SCV’s investigative powers or Eastern Health.

The spokeswoman instead said the department “always put patients first”, creating SCV and introducing guidelines for greater transparency after adverse incidents in 2022.

An SCV spokeswoman said their review was “comprehensive” and they were “closely monitoring” recommendations’ progress including the development of a new guidance document for managing acute anaphylaxis in kids.

“We work closely with health services to share lessons and constantly refine and improve their processes so each and every patient can receive the very best care,” she said.

A Health Department spokeswoman said it worked closely with all health services on meeting “national and state standards, including for patient care, sentinel event reporting and governance”.

An Ambulance Victoria spokeswoman said it was “deeply committed to implementing the recommendations for improvement in our patient care” from the SCV review.

“AV takes very seriously its commitment to patient safety,” she said.

AHPRA said they could not comment on individual matters.

All spokespeople said their thoughts were with the McKenzies.

‘We wake up in pain and we go to sleep in pain’

More than two years after their son’s tragic death, Ben and Tamara McKenzie sit in his bedroom and remember the incredible boy they lost.

All that has changed in Max McKenzie’s room since he died is the bevy of loving tributes that now fill the room and serve as a reminder of just how many people miss the “larger than life” 15-year-old.

Collages made by his “wonderful” friends – pictures of happier times – decorate the wall leading to his room.

A paddle lies across his bed, a testament to his love of kayaking and, on the shelf above, sit a row of shiny, white iPhone boxes.

Family and friends were always giving him their empty ones and, to this day his collection still grows, carried on his memory.

Down the hall in the living room, the Lego sets Max built with his sisters Ella and Lucy – who in true sibling fashion he both adored and annoyed – are still displayed, one of many family traditions cut short.

Ms McKenzie remembers her son as a “loud, energetic and fun” teenager, who teachers always said could get so much more work done if he just stopped chatting.

But that was Max. She says he loved to chat about anything and was involved in everything – from kayaking, debating and skiing to cadets, rotary, and school choir and productions.

“The house is very, very quiet without him,” she says.

“Max loved life so much and always made the most of every opportunity.

“I could not be more proud of the incredible boy he was. Max brought people together and he continues to do that today.”

In the words of his devastated father Dr Ben McKenzie, in the time it would have taken Max to watch just one episode of his favourite sitcom – Brooklyn Nine Nine – he was let down by the very system that was supposed to save him.

“Our lives are unbearable without him,” he says.

“His sisters Ella and Lucy miss him so much.

“We wake up in pain and go to sleep in pain.”

No matter how much they wish otherwise, they cannot turn back time and stop Max from walking out this bedroom one last time.

But they do hope, by speaking out, they can keep other children safe.

“He was larger than life”, Ms McKenzie says, “and life will never be the same without him”.

“Max was my whole world.”