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When 13-year-old Victorian boy Louis Tate was admitted to hospital for asthma, it was the one place his parents felt he would be safe.
But the next morning he died following an anaphylactic reaction to the mouthful of Weet-Bix and soy milk he was served for breakfast.
Coroner Phillip Byrne found on Monday the breakfast was a contributing factor in the Mt Martha boy's death. He also found significant systemic failures in Frankston Hospital's food handling practices at that time.
Louis's parents Simon Tate and Gabrielle Catan were satisfied the coroner confirmed their belief - that there were allergens in his breakfast. They will now pursue civil action against Peninsula Health.
"Ultimately we know if he hadn't had breakfast he would've been back home with us and we would not be here," an emotional Mr Tate said outside court.
Louis died in October 2015 from the extremely rare condition malignant hyperthermia.
He was admitted for overnight observation for asthma and had a history of allergies to cow's milk, raw egg and nuts.
His parents advised the hospital of his allergies, food requirements and that Louis had an EpiPen in his bag.
Louis's nurse documented the details, but nothing was written on the pediatric kitchen whiteboard about his allergies, as per protocol, and there was nothing recorded at his bedside.
After eating Weet-Bix and soy milk the next morning, his lips began tingling and his condition deteriorated.
He was given adrenaline and then suffered a reaction to the anaesthetic agent used to facilitate his intubation.
Louis developed malignant hyperthermia, had a cardiac arrest and couldn't be revived.
The coroner said it was one of the saddest cases he had dealt with in decades.
He made no adverse finding about Louis's medical care after the anaphylactic reaction.
However, he was frustrated at being unable to pinpoint the allergen that sparked the reaction, because it was unknown if the milk which underwent forensic testing was from the same carton as that fed to Louis.
"Whether it was mistakenly cow's milk in the glass or some other contamination due to dairy product, regrettably I am unable to determine," Mr Byrne said.
Peninsula Health had since put in "thorough and appropriate" food handling guidelines, relieving him of the need to make recommendations, the coroner noted.
This was disappointing for Louis's parents, who want a Senate inquiry into how hospitals prepare food and changes to the "outrageous" policy preventing hospital nurses from administering EpiPens.
Ms Catan said they felt their boy's food allergies were not taken as seriously as they should have been.
"We just hope parents with children with food allergies are going to really remain vigilant because we believe it's not safe out there for them."