It should never have happened: the Louis Tate Case

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The Australian Hospital & Healthcare Bulletin, 2018, Autumn, 2018 pp. 12 - 14 (3)
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The death of 13 year old Louis Tate at Frankston Hospital in Victoria made headlines across the country. Tate, who had a well-managed but severe allergy to cow’s milk, nuts and eggs, died at Frankston Hospital following a severe anaphylactic reaction caused by food served to him by the hospital. Tate required intubation, and died from a rare complication of anaesthesia, malignant hyperthermia. The findings of a coronial inquest into his death were recently handed down. The inquest raised a range of issues, especially bringing attention the need for all hospital services and activities – not only the obviously ‘clinical’ ones – to be an active part of the patient safety agenda and the need for hospital and health services staff to follow proper procedures for securing evidence for internal investigation and potential coronial cases.
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