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.
“Specifically, World Challenge and Kilvington Grammar School failed to support their staff to have the necessary intelligence about Type I Diabetes that would have supported them to address Lachlan’s illness in an informed and timely manner,” she said.
“No supervising adult on the Vietnam trip had specific training around diabetes management, the potential impact of intercurrent illness to a person with diabetes, or sufficient familiarity with the symptoms of high blood glucose levels/hyperglycaemia, ketone testing or DKA.”
Lachlan, whose T1D was first diagnosed at age nine, used both a blood glucose monitor and an insulin pump and had never been diagnosed with DKA previously, and while his diabetic control was described as “not ideal”, it was also fairly typical for a teenage boy, the inquest heard.
Nevertheless, he received medical clearance to attend the trip from his GP, supported by his regular endocrinologist, who prescribed him both long-acting and short-acting insulin to bring with him.
Despite the fatal outcome of the trip, the coroner did not criticise the decision, noting evidence from expert witness and paediatric endocrinologist Professor Timothy Jones that he was not suggesting that an adolescent with less than the aspirational level of 7% HbA1C should not be allowed to go on a camp.
Professor Jones said that diabetes is difficult and mental health problems are common in adolescents with T1D and not allowing them to do the youthful activities that their friends are doing would not be helpful to them, she noted.
As a result, through planning and having mitigation strategies in place to prevent serious consequences, endocrinologists do their best not to block them from participating, he said.
“Professor Jones said that some of these mitigation factors included meeting with the family, the child, the team they are travelling with, increase their education about their condition – to try to put things into place to stop this event from happening,” the coroner noted.
“Unfortunately, there was no collaborative approach to Lachlan’s diabetes – to the putting in place of the mitigation factors that might have prevented his untimely death.”
But she recommended the tour company ensure that, in future, medical clearance to attend an expedition was obtained from the student’s specialist, if the specialist was attended on a regular basis.