After being admitted to Frankston Hospital in October 2015 for asthma, Louis Tate was kept overnight for observations.
Gabrielle Caton, the young boy's mother, told a coronial inquest she made hospital staff aware of Louis allergies to milk, nuts and eggs and advised them WeetBix and soy milk was the best breakfast option for him.
Hospital staff proceeded to give Louis WeetBix and Freedom soy milk and shortly after eating the hospital supplied food, he complained to a nurse his mouth was 'tingling.'
Gabrielle was notified and immediately made her way to the hospital.
Doctors were also notified and Louis was administered with four shots of adrenaline before an anaesthetic to assist his breathing.
It was then that Louis parents were given the heartbreaking news. Their son had passed away from complications with the anaesthetic.
Ms Caton 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 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.'
After an inquest into the hospital's protocol, it was revealed that the hospital staff member who prepared Louis food that morning, Irene Fisher, was informed of the boy's allergies via a whiteboard.
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.