The grieving family of a diabetic teenager who died after falling sick on an international school trip has taken aim at a prestigious private school for its "offensive" suggestion that he contributed to a delay in his own medical care.
Lachlan Cook, 16, died in Melbourne's Royal Children's Hospital after being flown home from Vietnam, where he was on a trip with Kilvington Grammar School, and his death is now the subject of an inquest.
The blistering comments from the family's lawyer come as Coroner Audrey Jamieson indicated that she would be finding that his death was "preventable".
"There were a number of opportunities lost to provide appropriate oversight… and opportunities lost to provide him appropriate medical attention," the coroner said.
Lachlan was suffering from diabetic ketoacidosis, a serious complication of type 1 diabetes which happens when a patient's body cannot produce enough insulin.
He first fell ill as his travel group neared the city of Hue, about two weeks after they arrived in the country.
The leader of the expedition, from overseas adventure group World Challenge, believed he was suffering from gastroenteritis.
But his condition deteriorated quickly and within 24 hours he had suffered a heart attack and had to be resuscitated.
He was flown back to Melbourne where he was declared brain dead, and his life support was turned off.
Family's lawyer rejects suggestion Lachlan contributed to delayed care
On Thursday, lawyer Andrew Woods, who is representing the Cook family, told the final day of the inquest that it was "breathtakingly negligent" for Lachlan to be left in charge of his own diabetes and denounced Kilvington Grammar.
"Lachlan was a child. He was in the care of adults. He was entrusted into Kivlington's and World Challenge's care," Mr Wood said.
"Kilvington directly blames Lachlan's mother for a lack of communication."
Mr Woods also pointed to Kilvington Grammar's submission to the coroner, which said that Lachlan "contributed to the delay in that he reported at all times… that his blood glucose levels were OK when they were not".
"Given the profound effects of ketoacidosis, [it] isn't known at what level Lachlan was cognitively functioning. He took the sugary drinks mistakenly offered to him throughout the day, the exact wrong thing to offer.
"He was a minor… that's why you have teachers in charge of students."
But Mary Anne Hartley QC, who is representing the school, told the coroner that Kilvington Grammar acted "appropriately".
"There's no evidence to suggest that Lachlan was other than cognitively competent and able to make appropriate decisions himself about his care," she said.
"The school believed that the trip would operate with a substantial foundation of a well-trained and resourced expedition leader, backed by a 24/7 medical support system and that in any event, Lachlan would capably manage his own condition … excepting an emergency situation."
The coroner heard that Lachlan was diagnosed with type 1 diabetes when he was nine years old and monitored it himself, meeting with his endocrinologist and educators.
He was cleared by a GP and a paediatric endocrinologist to go on the expedition, who both said he was fit to travel.
Trip leader's actions to seek medical care scrutinised
On September 26, 2019, about two weeks after arriving in Vietnam, Lachlan told World Challenge trip leader Anna Walsh that he had vomited and was unable to hold down liquids.
The coroner was told that he continued vomiting and complained about abdominal pain, which Ms Walsh believed was gastroenteritis.
She reported Lachlan's condition to the World Challenge operation centre but was advised to continue the trip based on that diagnosis.
The coroner heard that the person who gave her that advice, Stuart Thomas, did not know that the teenager had diabetes.
The inquest was also told that it was not mentioned by Ms Walsh when she was asked about Lachlan's medication or symptoms.
On September 27, 2019, his condition deteriorated and he became verbally unresponsive.
He was taken to hospital where he had to be resuscitated.
Leading Senior Constable Dani Lord, who is assisting the coroner, told the inquest that there were "critical failings".
"The constant theme through the evidence was that the Kilvington staff relied on what they believed was the superior qualifications of Anna Walsh and the medical backup of the World Challenge operation centre and their medical provider, Helix," the police officer said.
"The adults on the trip were ill-equipped to recognise and respond in a timely manner to Lachlan's deteriorating condition.
"The leadership team of Kilvington and World Challenge staff were underprepared in their knowledge of Lachlan's needs if he became unwell."
She told the court that even though there was a diabetes action plan, it was not taken on the trip, and that local medical help should have been sought sooner.
The inquest heard that Ms Walsh, the expedition leader, contacted the World Challenge operation centre about Lachlan's diabetes but her message on the messaging app Viber went unread for "several hours".
The operation centre was then unable to contact any of the adults on the trip for four hours, which still cannot be explained.
The family's lawyer, Mr Woods, said there were many "missed opportunities".
"Anna Walsh looked in on Lachlan and then simply went to bed and fell asleep. She has no idea whether her phone was on silent," he said.
"If rather than going to sleep, Ms Walsh had continued to follow up her message to the operations centre regarding Lachlan's diabetes and continue to contact them until she had appropriate communication, it's likely that he would have received medical attention and would not have died.
"He needed the kind of care which World Challenge had promised it would provide 24 hours a day, seven days a week."
School's lawyer argues ignorance about risks of Lachlan's condition
Kilvington Grammar's lawyer, Mrs Hartley, said her client did not know a "significant" amount of information, including that Lachlan had not been taking "sufficient" blood glucose testing and had no had access to a diabetes educator to prepare for the trip.
"The school submits that if it had been informed accurately of the issues facing Lachlan … the school would have ensured active supervision of Lachlan," Mrs Hartley said.
"The school was led into a state of ignorance about many of the risks it was facing in relation to Lachlan.
"That ignorance… resulted in the school proceeding on the basis that Lachlan had been cleared to go on the trip and that the consequences of his diabetes would be adequately managed by World Challenge."
Coroner Jamieson on Thursday acknowledged that World Challenge and Kilvington had taken preventative measures, including diabetes training for teachers.
World Challenge leaders are now also trained in a new policy about phone volume.
The coroner will hand down her findings at a later date.
