Simon Tate and Gabrielle Catan were just starting to let go. After 13 years of closely monitoring every piece of food their son Louis touched, the couple could see their boy was starting to manage his allergies by himself.
As a fledgling teen, Louis Tate was going on camps, where he would negotiate his allergies to milk, eggs and nuts – a potentially life-threatening problem his carers were always well briefed on. He was also trying new restaurants with his family, so he knew exactly what he could safely eat while out with his friends.
But the athletic year 7 student was always prepared for the worst. The fear of anaphylaxis loomed large, forcing him to carry an EpiPen everywhere he went. He knew how to use it and so did everybody entrusted by his parents to care for him.
Even in hospitals, Louis’ family remained vigilant. When his asthma flared seven weeks ago, Gabrielle took him to Frankston Hospital for treatment. She says she advised staff of his allergies when they were examining Louis and that a red band was put around his wrist to flag his special needs.
At the hospital that night on October 22, Louis was diagnosed with mild to moderate asthma. A doctor decided to keep him overnight for monitoring. When Gabrielle left him in a ward about 1.30am to sleep, she thought he was safe.
“I told the nurse that he would be hungry in the morning and that the safest foods for him were soy milk, Weet-Bix and fruits,” she said.
The next day, Louis woke and was noted to be “alert and happy” by hospital staff caring for him. But when Gabrielle called to inquire about him at 7:19am, the nurse said he was complaining of tingling in his mouth and tightening of his throat after eating Freedom soy milk with Weet-Bix.
“I said ‘This is an allergic reaction’,” Gabrielle said. “The nurse said a doctor was with him.”
About 40 minutes later, somebody from the hospital called again to say they had given Louis adrenaline. It was the beginning of a nightmare the couple hope no other family will ever endure.
When Simon arrived at the hospital around 8:45am, he was told Louis needed an anaesthetic so they could help him breathe. The doctors wanted to transfer him to the Royal Children’s Hospital for more specialist care.
“I saw him briefly. He was on a trolley. He was distressed,” Simon says.
As doctors worked to stabilise Louis, Simon held his hand. He could see things going up and down on monitors attached to his boy, but Simon says an anaesthetist reassured him that everything was OK.
“Then they started saying that the Royal Children’s Hospital team were not there yet. I was getting anxious, so I walked out to get some air.”
Louis Tate loved playing video games and going to the beach. Photo: supplied
A short time later, Simon saw a red flashing light. He says somebody came out to tell him his son had suffered a complication from the anaesthetic. They confirmed his worst fears. Louis’ young heart had stopped. Staff tried to resuscitate him for an hour, but he was gone.
Simon and Gabrielle are still coming to terms with the sudden loss of Louis – a thriving, clever teen at Dromana Secondary College who had never had to use his EpiPen before and had well controlled asthma.
While the couple have been told by Frankston Hospital staff that Louis suffered a reaction to the anaesthetic, they fear his breakfast contained foods or traces of foods he was allergic to, causing anaphylaxis.
They are also concerned about how long it took hospital staff to give him adrenaline after he showed signs of an allergic reaction to food. Medical records show Louis received four adrenaline shots that morning. One at 7:39am, one at 7:55am, one at 8:14am and the last at 8:42am.
Guidelines written by the Australasian Society of Clinical Immunology and Allergy say adrenaline is required for any sign of anaphylaxis including tightness in the throat, and that if there is uncertainty about the symptoms being asthma or anaphylaxis, the adrenaline should be given first. The guidelines also say that further doses of adrenaline may be given if there is no response after five minutes. A different set of guidelines written by the Royal Children’s Hospital says doses should be repeated every five minutes if anaphylaxis persists.
The case, believed to be the first fatality linked to food preparation in a hospital, is now being investigated by the Coroner. Frankston Hospital is also reviewing Louis’ death and its policies and procedures, with input from independent experts.
While those investigations are under way, Louis’ family want all health authorities and families affected by food allergies to be aware of the tragedy, and the need for standardised management protocols, meticulous food preparation and swift treatment for anaphylaxis when it occurs.
Maurice Blackburn medical negligence principal Kathryn Booth said Louis’ death raised critical patient safety questions, including what food he was given, how it was given, and how his symptoms were managed.
“Louis’ parents deserve answers and measures need to be put in place to ensure this never happens at any other hospital,” she said.
President of consumer group Allergy & Anaphylaxis Australia Maria Said said she had heard of many near misses in hospitals for people with food allergies, but not a fatality in the last 25 years. She said while deaths from food in schools, early childhood centres and on school camps had been a catalyst for more rigorous procedures, there were no consistent guidelines or management protocols operating in all Australian hospitals to her knowledge.
“This could have happened in any hospital in Australia,” she said. “Our organisation tells people with food allergy that hospitals are dangerous places. You cannot let your guard down. You have to check the food and even bring food in from home because there aren’t strategies to get accurate information on food content in place to give you confidence.”
A spokeswoman for Victorian Health Minister Jill Hennessy extended her deepest condolences to Louis’ family and said while investigations were under way, she would not comment on the case.
A Department of Health spokesman said all hospital kitchens in Victoria were required to be registered as a Class 1 food premises under the Victorian Food Act 1984. This means they must prepare food that is safe to eat, have a food safety supervisor, and undergo two mandatory compliance checks a year.
The spokesman said the Australia New Zealand Food Standards Code also mandates warnings and advisory statements with respect to food allergens on food for sale in Australia. “The food provided in hospitals is captured in the definition of “sale” under the Food Act,” he said.