James Tsindos, 17, went into cardiac arrest on May 27, 2021, after experiencing an anaphylactic reaction to a burrito bowl he had ordered off the now-defunct Deliveroo app.
Victorian coroner Sarah Gebert on Friday found miscommunication and a delay in administrating a third shot of adrenaline were missed opportunities to provide care for James.
But she ultimately could not say whether James would have survived if the circumstances were different.
In a statement, the boy's family thanked the coroner for highlighting those missed opportunities.
"We, like the coroner, hope that the terrible circumstances of James' death can be used to keep other patients safe in the future," the statement read by senior counsel Shari Liby said.
"While our family home is no longer filled with the sound of James at the piano, we do feel some gratitude to know that his death has not been in vain."
James, who was sensitive to nuts but not diagnosed with anaphylaxis, did not realise the burrito bowl he had ordered contained a sauce made from cashews.
He began experiencing allergy symptoms after eating the meal, including swollen lips and abdominal cramps, and his father called an ambulance.
Paramedics arrived at their Brighton home in Melbourne's southeast about 2.50pm on May 27 and administered two doses of adrenaline five minutes apart.
His symptoms improved but he was transferred to the nearby Holmesglen Private Hospital as a precaution.
As he arrived at the hospital, he told the paramedics he was "wheezy" and, given he also had diagnosed asthma, he self-administered 15 puffs of his Ventolin inhaler.
James was moved into an isolation room and the paramedics provided a handover to a triage nurse, indicating James had developed a wheeze.
During the inquest, the triage nurse claimed he was not told about the symptom although the coroner found it had been relayed by the paramedics.
"This was the most significant missed opportunity," Ms Gebert said in her findings.
"If (the nurse) had been aware of the presence of the wheeze ... he would have alerted the doctor to come and see (James) immediately."
The coroner said the second missed opportunity was when James was assessed by a different bedside nurse in the isolation room.
The nurse noted the boy's need for additional Ventolin and his mild difficulty breathing but did not recognise the symptoms as a further emergence of anaphylaxis.
It was only after James said "I can't breathe" that a doctor was called and a third dose of adrenaline was administered.
James went into cardiac arrest and he was transferred to The Alfred hospital but he never recovered.
His life support was turned off on May 29.
Despite the missed opportunities in the boy's care, the coroner could not find his death was preventable.
She noted a panel of experts had reviewed the case and had differing opinions on his ultimate prognosis.
"James' chances of survival would no doubt have been greater had he been given adrenaline sooner," Ms Gebert said.
"However I do not have a proper basis to choose between the expert opinions in order to provide that certainty, and I express my regret to the family that I am unable to do so."
The coroner made eight recommendations, including that Safer Care Victoria consider developing a statewide approach to the treatment of anaphylaxis in hospitals.
The Tsindos family said they hoped the coroner's strong recommendations would be heard and acted on.
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