Finding into death of Louis Oliver Tate

Contributing factors

• Anaphylaxis resulting from an undetermined allergen in breakfast provided
• Deficient food handling procedures and lack of written allergen policy
• Failure to document patient allergies on kitchen whiteboard
• Failure to check prepared food for allergen-free status before delivery
• Systemic failures in food service allergy management

Coroner's recommendations

1. Development of mandatory national Clinical Care Standard for Anaphylaxis across all Australian jurisdictions and healthcare facilities
2. Uniform adoption of ASCIA Acute Management of Anaphylaxis Guidelines with consistent implementation across primary, secondary and tertiary care
3. Implementation of comprehensive allergen management protocols including documented allergies on kitchen whiteboards and bedside signage
4. Mandatory verification by nursing staff that prepared meals match patient allergen requirements before delivery
5. Preparation of allergen-free meals in main kitchen with signed documentation of recipe adherence and cross-checking by personal care assistants and nurses
6. Storage of allergen-free meals on separate red trays with multiple identifier checks (patient UR number and red alert ID bands)
7. Training for all food service staff, personal care assistants and nurses on allergen management and cross-contamination prevention, minimum annually
8. Development of guidelines permitting health professionals to administer a patient's personal EpiPen in healthcare settings when ASCIA Action Plan is available
9. Acceleration of Australian Commission for Quality and Safety in Healthcare work on developing a national Clinical Care Standard for Anaphylaxis