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In December 2013, 10-year-old Melbourne boy Ronak Warty died after consuming a coconut drink that contained milk. Ronak was allergic to milk; however, the product’s labelling failed to declare its presence. The June 2016 release of the coronial inquiry into Ronak’s death focused attention on how anaphylaxis was managed in Victoria.

In response to this and other cases, Victoria’s Chief Medical Officer of Quality and Safety reviewed sentinel events and several allergy and anaphylaxis clinical incidents in Victorian hospitals.

This identified the need for a consistent, system-wide view on how acute anaphylaxis is managed in Victorian hospitals.

After receiving advice from the Victorian Paediatric Clinical Network (VPCN), Safer Care Victoria released the June 2017 discussion paper, Mandatory reporting of anaphylaxis.

Page last updated: 13 Nov 2020

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