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Hospital breakfast caused allergic reaction which led to boy's death, coroner finds

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Louis Tate was just hours away from being discharged from Frankston Hospital when the 13-year-old was served breakfast. But what exactly was in that meal? And did it cause his death?

On Monday, Coroner Phillip Byrne concluded that the Mount Martha teenager suffered anaphylaxis from an “undetermined allergen” in the morning meal provided to him.

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Hospital breakfast led to boy's death

The parents of Louis Tate, the 13-year-old Melbourne boy who died in Frankston Hospital in 2015 say he would still be alive if not for the breakfast he was served at hospital.

Louis had an allergy to cow's milk, nuts and eggs. But it had been a point of contention if any of those things had tainted the Weet-Bix breakfast served to him while he was in hospital for an asthma episode in October 2015.

His family say Louis would still be alive now if he had not eaten a spoonful of hospital breakfast that morning.

But despite the sporty year- 7 student complaining of tingling to his lips immediately after tasting the Weet-Bix, the hospital had refused to concede the meal was responsible for an allergic reaction, only agreeing that it was “possible”.

Mr Byrne sided with the family on this debate, saying on Monday that the breakfast did contain a mystery allergen, and finding that the food handling practices at Frankston Hospital, since overhauled, were “clearly deficient”.

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However, the family may never know what was in the meal that caused the reaction, because the hospital did not keep it as evidence, according to information presented to the court.

Coroner Byrne said he could not even be sure if a carton of soy milk delivered to the Victorian Institute of Forensic Medicine was the one that contained the milk that Louis was served.

Frankston Hospital has so far refused to comment on the question of what happened to the breakfast, though during the inquest the court heard that Louis' mother Gabrielle Catan was given the impression that the breakfast was thrown away and not retained for testing.

"We were just told 'Oh, we didn't know that it would go so wrong and he would die'," Ms Catan said.

Louis was admitted to the Melbourne hospital on October 22, 2015, after coming home from school with laboured breathing.

His mother left the hospital early the next morning to let her son sleep, with firm instructions to the nurse on how to locate Louis' EpiPen and what he should eat when he woke up.

"I told her that the safest food for him for breakfast was Weet-Bix, because it is widely available, and soy milk and if, he needed anything else, maybe fruit," Ms Catan told the inquest.

"I really thought about the safest, simplest food that he could have that was readily available."

However Louis' allergies were not recorded by the nurse on a whiteboard in the paediatric ward kitchen and he fell ill shortly after he was served breakfast by a personal care assistant who had been verbally instructed to use soy milk.

Hours later he was dead – after he suffered a cardiac arrest and could not be revived.

On Monday Mr Byrne found Louis’ death to be caused by malignant hyperthermia due to a rare reaction to an anaesthetic agent during his treatment, a prospect he said could not have been reasonably anticipated.

But he also said the anaphylaxis that Louis experienced after eating breakfast was a “contributing factor” to the death.

Louis father, Simon Tate, said he was pleased the coroner had found that there were allergens in the breakfast, but disappointed that Mr Byrne had made no recommendations that might help other allergy sufferers in the community.

The family said they will sue the hospital and are also calling for a national Senate inquiry into how hospitals prepare food.

“We know if he hadn’t had breakfast, he would be back home with us, and we would not be here,” Mr Tate said.

“I hope no one is back here in two years time with a similar type of tragedy.”

After an external review following Louis’ death, the Frankston Hospital made a number of changes. They no longer decant milk on the ward, providing only single-serve unopened packs. And food given to allergy patients must be checked off by a nurse.

Dr Tim Williams, executive director of medical services at Peninsula Health, which manages Frankston Hospital, said the hospital accepted the coroner’s findings.

“The safety of our patients is our number one priority, and we have made a number of changes to our processes and protocols in the hospital since Louis’ tragic death in 2015,” he said.

“The thoughts of everyone at Peninsula Health are with Louis’ parents, family and friends at this extremely difficult time,” he said

Kathryn Booth, medical negligence principal from Maurice Blackburn Lawyers, said because of Frankston Hospital’s flawed investigation, Louis’ family would never know what caused his allergic reaction.

“Right to end of this inquest things were not clear, despite it having been in the coroner’s hands for years, we were still following the milk trail,” she said.

A spokesman for Health Minister Greg Hunt said the minister would support a Senate inquiry ‘‘into either the specific question of food safety in hospitals or a broader inquiry into food safety in general, for those with allergies’’.

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