Tragic Death of Riley Brown Highlights Critical Gaps in Mental Health Facility Safety

On 1 June 2025, Riley Brown, a 24-year-old man with a severe peanut allergy, died at a mental health respite facility in Nelson, New Zealand. His death has sparked outrage and renewed calls for improved safety protocols in mental health care settings, particularly concerning food allergens and patient communication.

Anaphylaxis Confirmed as Cause of Death

A post mortem examination confirmed that Riley’s death was caused by anaphylaxis due to his peanut allergy. The toxicology report revealed that the meal he consumed contained trace amounts of peanut allergen—594.9 parts per million—well above the levels typically considered safe for food labeled as peanut-free.

The report also showed an elevated serum tryptase level of 32.3 micrograms per litre, a biochemical marker strongly associated with anaphylaxis. Pathologist Dr. Mark Houghton confirmed the presence of peanut allergen in Riley’s gastric contents and noted that the meal included an ingredient with trace peanut traces.

Prompt Response Did Not Prevent Tragedy

Despite the administration of intramuscular adrenaline immediately after Riley began showing symptoms, the treatment had limited clinical effect. Riley had previously expressed concerns to his mother, Paula Brown, about the possibility of the meal containing nuts, even though he was assured it was nut-free.

Two hours after dinner, Riley felt unwell and walked into an ambulance, where he suffered a cardiac arrest and later died. Paula Brown described the incident as a 'senseless waste of a life' and expressed her deep emotional struggle in coping with the loss.

Preceding Events and Systemic Concerns

Riley had contacted the Mental Health Crisis team a week before his death, reporting changes in behavior. He spent one night at the Nelson facility and was reportedly doing well before returning home. However, the incident has raised serious questions about the adequacy of the care provided and the communication between staff and patients.

Health New Zealand has acknowledged the incident and confirmed that a review of the care provided is underway. Mental Health Minister Matt Doocey expressed his condolences and emphasized that a thorough review is necessary to determine whether safe, high-quality care was delivered.

Calls for Accountability and Reform

The tragic death has prompted widespread calls for accountability and for improved safety measures in mental health facilities. Advocates are urging stricter food handling protocols, better communication with patients, and more robust training for staff to prevent similar incidents in the future.

As the investigation continues, the community and mental health sector are left grappling with the painful reality that a young life was lost due to preventable negligence. This case serves as a stark reminder of the need for continuous improvements in mental health care to ensure that all patients receive the protection and respect they deserve.