Louis Tate was admitted to Frankston Hospital in October 2015 for asthma, and the young boy was kept overnight for observations.
The 13-year-old Victorian boy was given breakfast by hospital staff the next morning, to which he suffered an anaphylactic reaction.
Coroner Phillip Byrne found on Monday the breakfast was a contributing factor in Tate's death. He also found significant systemic failures in Frankston Hospital’s food handling practices at that time.
Gabrielle Caton, the young boy's mother, told a coronial inquest she made hospital staff aware of Louis allergies to milk, nuts and eggs.
Hospital staff proceeded to give Louis WeetBix and what was said to be Freedom soy milk and shortly after eating the hospital supplied food, he complained to a nurse his mouth was 'tingling.'
Following the reaction Louis 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 couldn’t be revived.
Louis mother said, 'I thought because we were in the hospital, the medical staff would know exactly how to take care of him.'
'I didn't feel I needed to say anaphylaxis was a life-threatening condition,' she said.
The Coroner was unable to pinpoint the allergen that sparked the reaction, as it was undetermined if the milk which underwent testing was from the same carton given to Louis.
'Whether it was mistakenly cow's milk in the glass or some other contamination due to dairy product, regrettably I am unable to determine,' Mr Byrne said.
The young boys father, Simon Tate, said in a statement: 'We strongly believe Louis' death never should have happened. He was in hospital, at a place where he should have been safe. Yet despite us providing clear and concise communications about his food allergies, he died.'
The coroner found systemic failures in Frankston Hospital's food handling practices. Although details of his allergies were noted upon admission, nothing was written on the pediatric kitchen whiteboard and there was nothing recorded at his bedside.
Louis' parents also expressed concerns about how long it took medical staff to administer adrenaline after the allergic reaction.
The inquest revealed that Louis did not receive treatment until 10 minutes after first complaining.
A senior nurse, who was present on the day, gave evidence that prior to Louis' death nursing staff at the hospital did not receive training or have the authority to administer treatment without a doctor present.