00:09the
00:09The hospital is where people are meant to be safest their doctors provide them with the care and medication that
00:15they need to get better
00:16But Lewis Tate didn't get the healing. He needed instead. He was served a deadly breakfast
00:23Lewis did checked into Frankston Hospital in Victoria Australia in
00:272015 because he felt sick from asthma the 13 year old and also suffered allergies to raw eggs
00:33Nuts and cow's milk, but his health concerns were well managed according to his mother Gabriel Catan
00:40Although Lewis was only a teenager. He had an anaphylaxis action plan. He always has an EpiPen
00:46Gabriel told ABC News he knew to ask hospital staffers for a safe breakfast for him to eat wheat cereal
00:53and soy milk
00:54With Lewis's mature handling of his medical needs Gabrielle likely had no problem leaving her son overnight in the hospital
01:00She departed at 1 o'clock in the morning and called to check in a few hours later around the
01:06time that he'd be eating his breakfast
01:08That was when Lewis's mother knew that something had gone terribly wrong
01:11The nurse on the other end of the line said he had a good night
01:15But he just came over to me to tell me he has a slight tingling sensation in his mouth
01:19Catan recalled with that his mother knew exactly what was happening. He was having an allergic reaction. That was quite
01:25clear
01:26Gabrielle said Lewis had only eaten a single bite of his breakfast when he felt the telltale signs and
01:32That one bite would prove to be fatal from the moment Lewis's lips began tingling the 13 year old's condition
01:39got worse
01:40Extremely quickly he died in the hospital leaving his family with nothing but questions
01:46Lewis's father Simon said we continue to struggle every day with the emptiness loss and circumstances surrounding his death
01:54But the family had a suspicion that their son's breakfast was to blame for his quick unexpected passing
02:00We strongly believe that Lewis's death should never have happened
02:04He was in the hospital at a place where he should have been safe
02:07Yet despite us providing clear and concise communications about his food. He died his father added
02:14The 13 year old's family would have to wait more than two years after their son's death to find out
02:19what had actually happened to him
02:21During the inquest they learned some upsetting details about the hospital's handling of Lewis's allergies
02:27In December of 2017 the nurse in charge of Frankston hospital's children's ward Helen Hutchins
02:33Admitted that Lewis's allergies hadn't been written on the kitchen whiteboard as they should have been
02:38She called it a failure of the system according to ABC news
02:43But coroner Philip Byrne eventually found that there was more to blame for Lewis's death than a bad breakfast in
02:49February 2018 he revealed that the 13 year old had died from a disorder called malignant hypothermia
02:56Which was an incredibly rare disorder?
02:59Malignant hypothermia occurs when a patient has an extreme reaction to the medications administered during anesthesia
03:06Symptoms of the condition include a rapid heart rate high temperature and muscle stiffness
03:11Frankston hospital staff had indeed given Lewin an anesthetic for a very specific reason
03:16He had gone into anaphylaxis after eating his breakfast according to the coroner
03:21This meant that the boy's family suspicions about his case of death were partly correct
03:27Byrne also performed further research to figure out what exactly the hospital had given Lewis to cause the allergic reaction
03:34But he believed that forensic experts did not receive the right carton of milk from the hospital
03:39Preventing them from identifying the allergen present
03:42Byrne said I'm somewhat frustrated
03:45Whether it was mistakenly cow's milk in the glass or some other contamination due to dairy product
03:50Regrettably I am unable to determine
03:53Still the family felt vindicated by the coroner's findings
03:57Ultimately, we know that if he hadn't had breakfast he would have been back home with us, and we wouldn't
04:02be here
04:03Simon the boy's father said after hearing the results of the inquest
04:07He and gabrielle did have one problem with the coroner's findings though
04:12Although burn had indeed pointed out the hospital's poor food handling procedures
04:16He did not make any recommendations for improvements in the area
04:20Lewis's parents wished he had but the coroner said he didn't need to
04:25That was because in the wake of Lewis's death the hospital had revamped its food handling guidelines
04:30The coroner believed that they were now thorough and appropriate
04:33The hospital had begun putting patients allergies into a computer system
04:37So that they wouldn't be absent from the kitchen whiteboard as Lewis's had been and
04:42Although Lewis's parents finally had the results they knew to be true all along
04:46They still plan to do more in the wake of their son's untimely death and after hearing the coroner's report
04:52They said they plan to file a civil suit against Frankston Hospital
