The first aid provided to a young boy who choked to death at an Adelaide school was "hampered by panic and communication difficulties", with an inquest into his death to determine whether South Australian teachers are equipped to respond to first aid emergencies.
Lucas Latouche Mazzei was in reception at Henley Beach Primary School when he choked to death on a nectarine stone in March 2017.
Warning: This story contains details some readers might find distressing.
The five-year-old, who was in the special needs class, was watching his favourite cartoon The Gruffalo and was the only student in the classroom at the time.
The inquest into his death heard the other students had left the classroom to go to a science lesson, but Lucas had stayed behind because he was known to put "anything and everything" in his mouth due to his global development delay.
The inquest also heard the teacher supervising Lucas at one point left the classroom and the support staff person did not have a line of sight.
No staff member had seen Lucas put anything in his mouth and it is not known how long Lucas had been choking for unobserved.
Once staff became aware, they started first aid while waiting for an ambulance — including banging him on the back to try and clear his airway, holding him upside down in an attempt to clear his airway and placing him in the recovery position.
The inquest heard some of the first-aid provided was not in accordance with the recommended guidelines by the Australian Resuscitation Council.
At one stage, a staff member brought a defibrillator to the classroom that was still in packaging and needed to be unpacked.
Counsel assisting the coroner Emma Roper told the inquest all staff provided first aid to the best of their ability and they were not to be criticised.
However, she said a focus of the inquest would be the competency of first-aid training provided to school staff and whether at any stage Lucas's death could have been prevented.
"There was a delay in commencing resuscitation and the ambulance arrived before CPR was commenced," she told the inquest.
"No chest thrusts were performed by the staff present, this was despite the fact that they had all had first aid training as recently as February … and chest thrusts were part of that curriculum."
Up-to-date first aid not required for teachers
Ms Roper said at one point one of the staff members had to leave the room "because she was overcome with emotion".
She said it was not a requirement of public school teachers in South Australia to have up-to-date first aid training, instead a certain number of designated first-aid staff were required, and the inquest would probe whether teachers were "properly equipped to respond to a first aid emergency should the need arise".
"At the time of Lucas's death, none of the persons present had completed the course specifically designed for people working with children," Ms Roper told the inquest.
"The Department for Education did not, and does not, require this level of training to be undertaken by teachers in public primary schools.
"Ultimately this inquest will consider the issue of whether appropriately administered first aid could have prevented the death of Lucas."
Parents want answers about death
After a coroner's viewing of the school, an advocate for Lucas's family, Professor Richard Bruggemann, said Lucas's parents wanted answers and to ensure no other child died in similar circumstances.
"A young boy has died on his third or fourth week at school. Five years later, the family don't know how that happened," he said.
"They equally don't know that this won't happen to another child.
"I could understand if we just said, 'oh, we're giving up'.
"They haven't done that, to their great credit, in the memory of their son in the hope it never happens to any other child.
"It's taken the family, his pro bono lawyers who have been working with them, me as a sort of amateur advocate, to get this onto the agenda.
"The really good thing about coronial reports is that they give us information about how to ensure how these things never happen again."
The inquest will also examine the “potential lapse of supervision” of Lucas, his medical conditions and the classroom supervision, and the roles they may have played in preventing his death.
The inquest before Deputy Coroner Ian White is expected to run for a week.
