A “laissez-faire” attitude among staff at a prestigious Melbourne private school contributed to the death of a student with T1D following a DKA episode on an overseas trip, a coroner has ruled.
Lachlan Cook, 16, died after falling ill on Kilvington Grammar’s expedition to Vietnam in September 2019, having begun vomiting and complaining about stomach pains about two weeks into the trip.
The expedition leader from World Challenge, the travel outfit that organised the trip, treated the illness as gastroenteritis but did not provide specific care for the boy’s T1D.
About 24 hours later, after his condition deteriorated dramatically, Lachlan was put in a taxi and taken to a local hospital where he suffered cardiac arrest and fell into a coma.
He was flown by air ambulance back to the Royal Children’s Hospital in Melbourne, where doctors declared him brain dead and his life support was turned off.
The boy’s cause of death was found to be severe DKA, most likely precipitated by a gastrointestinal infection.
Last month, Victorian Coroner Audrey Jamieson handed down her findings following an inquest into his death, ruling the incident was “preventable” (link here).
She said the school had a “laissez-faire” attitude to its responsibility for its students on the trip, saying it was complacent and reliant on the trip organiser World Challenge, and “assumed all would be well”.
This complacency and assumptions on the part of the boy’s parents, the school and World Challenge had contributed to his death “like a snowball gaining speed”.
“There was clear and cogent evidence the failing of World Challenge and Kilvington Grammar school contributed to the death of Lachlan McMahon Cook,” the coroner said.
Both parties had failed to ensure there was appropriate support for someone with diabetes on the trip and had failed to make sure there was Lachlan’s medical documentation, including his diabetes action plan, she said.
Instead they relied on the already ill 16-year-old to manage his own condition, the coroner found.