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 boyโs death. He also found significant systemic failures in Frankston Hospitalโs food handling practices at that time.

Louisโs parents Simon Tate and Gabrielle Catan were satisfied the coroner confirmed their belief โ that there were allergens in his breakfast. They will now pursue civil action against Peninsula Health.
โUltimately we know if he hadnโt had breakfast, he wouldโve been back home with us and we would not be here,โ 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 cowโs milk, raw egg and nuts.
His parents advised the hospital of his allergies, food requirements and that Louis had an EpiPen in his bag.

Louisโs 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 couldnโt be revived.
The coroner said it was one of the saddest cases he had dealt with in decades.
He made no adverse finding about Louisโs 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.
โWhether it was mistakenly cowโs milk in the glass or some other contamination due to dairy product, regrettably I am unable to determine,โ Mr Byrne said.
Peninsula Health had since put in โthorough and appropriateโ food handling guidelines, relieving him of the need to make recommendations, the coroner noted.
This was disappointing for Louisโs parents, who want a Senate inquiry into how hospitals prepare food and changes to the โoutrageousโ policy preventing hospital nurses from administering EpiPens.
Ms Catan said they felt their boyโs food allergies were not taken as seriously as they should have been.
โWe just hope parents with children with food allergies are going to really remain vigilant because we believe itโs not safe out there for them.โ
This article originally appeared on West Australian