Louis' parents Simon Tate and Gabrielle Catan are calling for changes to investigation protocols at hospitals. Credit:Simon Schluter His mother, Gabrielle Catan, said she left him in hospital for a few hours in the early morning of October 23 with firm instructions to feed him only Weet-Bix, soy milk or fruit for breakfast. The family believe Louis was likely given cow's milk, or contaminated soy milk, with his last meal. The hospital, however, maintains that Louis was given only soy milk decanted from a "Freedom" brand carton, but has been unable to explain what caused his anaphylaxis. "We don't know," said the hospital's barrister, Dr Paul Halley.

A picture of Louis supplied by his family. Dr Halley confirmed that the carton of soy milk was later "taken away", but no test results have emerged and the hospital are yet to publicly reveal what happened to this evidence. Last week Irene Fisher, the patient services assistant who prepared and served Louis the breakfast, told the coroner someone had asked for the milk on the day Louis died, though she could not recall who it was. "They wanted the milk to be analysed, that's what they said." Louis' family have called for police or another independent body to be involved investigating similar cases in the future, saying the coroner's inquest into Louis' death had been "hampered by lack of information" provided by the hospital.

"If the police is able to get to a motor vehicle accident where someone is complaining of a sore neck, why can't a similar occurrence happen here?" said barrister Chris Winneke, who is representing the family. "This sort of thing needs to properly investigated at the outset. "What should have been included in that investigation. at the very least, is the isolation of the food that Louis had eaten for testing." Louis' mother 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 last week.

Peninsula Health, which runs Frankston Hospital, has refused to comment on what happened to the meal. "As the matter is currently before the coroner, we are unable to make any further comment," said Peninsula Health's Tim Williams, the executive director of medical services. "The thoughts of everyone at Peninsula Health are with Louis' parents, family and friends at this extremely sad and difficult time." Because Louis only had a spoonful of his breakfast, his family say it is likely he stopped eating because he was able to taste the cow's milk, or noticed that there was something unusual. Shortly after he was served the meal, Louis approached a nurse complaining of tingling in his mouth.

A few hours later he was dead. Louis' heart stopped after he was administered an anaesthetic as doctors tried to manage his worsening allergic reaction. He was later diagnosed with malignant hyperthermia, a condition that triggers a severe reaction to drugs used as part of anaesthesia. The court heard that although Louis' allergies were severe, the clever and sporty Dromana Secondary College student had, for more than a decade, been able to comfortably avoid any exposure. Louis had been on camps, travelled overseas and would sometimes eat out at restaurants after he and his family researched them.

Frankston Hospital has conceded there were deficiencies in its protocols for food handling for allergy patients at the time of Louis' death, which they say have since been rectified as all food on the children's ward is now recorded on a computer system. Coroner Phillip Byrne will hand down his findings into the case next year.