Save articles for later
Add articles to your saved list and come back to them any time.
The death of a Kilvington Grammar student who went on a school trip to Vietnam was “preventable and a tragedy to all who knew and loved him”, an inquest in the Coroners Court of Victoria has found.
Coroner Audrey Jamieson found the failures of Kilvington Grammar in Ormond and travel group World Challenge Expeditions contributed to the death of 16-year-old Lachlan Cook in 2019.
Lachlan Cook died of diabetes-related complications in 2019.Credit: Facebook
Lachlan died in the Royal Children’s Hospital in Melbourne in October 2019 after becoming ill from severe diabetic ketoacidosis, a complication of diabetes, while overseas.
Jamieson said that no supervising adult on the trip had specific training around diabetes management.
She found Kilvington Grammar failed to support teachers on the trip by ensuring they had a copy of Lachlan’s diabetes management plan, and World Challenge failed to ensure its staff had all relevant documents relating to Lachlan’s “openly disclosed” medical condition.
“A significant opportunity was lost to the staff members to have the information that would have enabled them to act in an informed and timely way to the onset of Lachlan’s illness,” Jamieson said.
“I find that there is clear and cogent evidence that the failures and shortcomings of World Challenge Expeditions and Kilvington Grammar contributed to the death of Lachlan McMahon Cook.”
Lachlan, who was diagnosed with diabetes when he was nine and had received medical clearance to go on the trip, became unwell on a bus to Hue on September 26 and vomited twice.
His blood glucose, heart rate and temperature levels were monitored and he was given water, Panadol and anti-nausea medication.
The World Challenge trip leader had a conversation with Lachlan about checking his blood glucose levels during the night and Lachlan said if his levels got too high or low he would wake up and adjust them or ask for help.
Jamieson found that Lachlan was generally capable of managing his diabetes adequately on his own, but he should not have been expected to self-manage when it was apparent he was unwell.
Coroner Audrey Jamieson found “clear and cogent evidence that the failures and shortcomings of World Challenge Expeditions and Kilvington Grammar” contributed to Lachlan’s death.Credit: Penny Stephens
A Kilvington Grammar teacher checked on Lachlan at 5am the following morning, and while he was initially coherent, Lachlan said he had no energy and started to slur his speech.
The teacher found his blood glucose levels were high, and after checking again two minutes later, went to wake the World Challenge trip leader.
“Shortly after (the trip leader) attended Lachlan’s room, he became verbally unresponsive, his body became floppy and he was not able to stand,” Jamieson said.
He was taken to hospital, where the teacher used Google Translate on his mobile, to try to explain Lachlan’s condition to staff.
Lachlan was moved to intensive care but had a cardiac arrest and was flown by air ambulance to the Royal Children’s Hospital, where he was declared brain-dead and taken off life support.
Jamieson found Lachlan died from hypoxic-ischemic encephalopathy, a type of brain damage, due to the complication from his diabetes.
“The circumstances I find were easily avoidable and rectifiable before he lapsed into extremis,” she said.
“Having considered all the evidence and applying the requisite standard of proof, I find that the death of Lachlan McMahon Cook was preventable, and his death was a tragedy to all who knew and loved him.”
In a statement, Lachlan’s family said: “Today we learned that the death of our son and brother was preventable. To say this is heartbreaking defies the pain that this news causes.”
They said they could only hope that other schools and camp providers learned from their experience, and that people who accompanied children on school activities were vigilant and well-trained by their employers.
“You care for our children in our absence,” the statement said. “All families should have confidence that when their children participate, that they will return back home, and into their arms, healthy and safe.”
Kilvington Grammar said “the findings were, as expected, very challenging and difficult listening, and we are grateful to the coroner for the rigour and thoroughness of the inquest.”
The school said it had implemented several restorative practices since 2019 and would continue to apply these to ensure the safety of students both domestically and internationally.
“The thoughts and prayers of the Kilvington community are with the Cook family following the coroner’s findings today as they continue to grieve the loss of their son, Lachlan,” the school said in a statement.
World Challenge said its enduring thoughts had been with Lachlan’s family and friends since 2019.
“We constantly review and update our health and safety procedures and will continue to do so as we implement the final recommendations from the coroner,” it said in a statement.
Get the day’s breaking news, entertainment ideas and a long read to enjoy. Sign up to receive our Evening Edition newsletter here.
Most Viewed in National
From our partners
Source: Read Full Article
