A Victorian go-karting organisation knew about a teenager's nut allergy but failed to act before the 15-year-old unknowingly ate a macadamia cookie and died.
Jack Glen Irvine died in September 2012 after he ate the biscuit and went into anaphylactic shock.
The white chocolate and macadamia cookie was part of a lunch provided by the Victorian Karting Association (VKA) at a camp it was holding in Oakleigh.
VKA had been informed of the teen's nut allergy but "failed to take any meaningful steps" to act on the information, Coroner Audrey Jamieson said in her findings, which were released on Friday.
The coroner said Jack's death was preventable and made a number of adverse findings about the karting association.
VKA had no policies or procedures in place at the time on how to safely conduct a junior camp whose participants - including children - had food allergies.
Ms Jamieson found VKA made no meaningful attempt to cater for participants who had disclosed food allergies on their camp registration forms.
The catering process was inadequate and had no regard for the food allergies they knew about, she said.
For lunch on the camp's first day, the VKA had ordered food from Subway, which included a platter of mixed cookies, according to the coroner's report.
The food was laid out for camp participants, parents, and VKA volunteers, but there was no information about what the food contained, or where it was from.
After Jack picked up a cookie, his father, a VKA member, asked the teen if the cookie he had selected contained nuts.
The 15-year-old snapped it open and said it was white chocolate.
Mr Irvine then watched his son eat the cookie, neither aware that it contained macadamia.
About 40 minutes later, the teen started displaying symptoms similar to an asthma attack. He collapsed and was taken to hospital, where doctors later told his parents he would never recover.
They decided to donate his organs, and the 15-year-old died on September 30, 2012.
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