A South Australian coroner should find that the death of a reception student who fatally choked on a nectarine at school could have been prevented if he had been supervised, an inquest has been told.
Counsel assisting the coroner Emma Roper has also urged deputy state coroner Ian White to make a recommendation that all public school teachers have up-to-date first aid training, which is not currently required in South Australia.
Lucas Latouche Mazzei was in reception at Henley Beach Primary School when he choked to death on a nectarine stone in March 2017.
The five-year-old, who was in the school's special needs class, was watching his favourite cartoon, The Gruffalo, and was the only student in the classroom at the time.
His classmates had gone off 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.
Ms Roper told the inquest that Lucas needed to be supervised at all times, given the known risk that he could choke.
But, on the day of his death, the five-year-old was left unsupervised for up to 10 minutes in his special needs classroom.
"He did not die as a result of his rare medical condition. The cause of his death was choking on a nectarine seed and, in my submission, that could have reasonably been prevented by closer supervision.
"This was more than a momentary lapse in supervision."
Ms Roper asked the coroner to make a recommendation to the education department that all teaching staff be required to hold an up-to-date qualification in providing first aid in education and care settings.
Parents 'misled' over investigation
The lawyer for Lucas's parents, Paul Charman, agreed, telling the inquest that teachers at independent schools had a higher level of first aid training than public school teachers in South Australia.
"We say that's consistent with, and as a result of, a failure of the education department to undertake any inquiry or investigation into Lucas's death.
"If they'd undertaken any investigation at all, I would think it would have led to the need for increased training rather than a reduction of training."
Mr Charman said there was now a "two-tier level of training" separating public and private schools. He said that, unless that changed, parents should be aware of the difference.
"If you go to a public school, you should expect that the level of first aid training that staff at a public school have had would be less than if your child goes to an independent school or a Catholic school," he said.
Mr Charman also told the inquest the education department never carried out an investigation into Lucas's death and had "misled" Lucas's parents into believing they had.
"It is simply not enough not to conduct an investigation," he told the inquest.
The inquest has also heard that the first-aid provided on the instructions of a triple-0 operator was "hampered by panic and communication difficulties" and that the classroom involved was in a "dead spot" for phone reception.
Mr Charman told the inquest that it was "difficult to comprehend" how there could be issues with mobile phone signal in suburban Adelaide, let alone in a special needs classroom.
"Not even to have an extension of the landline in the main classroom, out of reach to students, knowing full well that mobile phones didn't work is … rather remarkable in this day and age, that such an issue existed and continues to exist," he said.
Ms Roper told the inquest the triple-0 operator was "not as robust as she could have been" in her instructions to the school staff administering first aid and provided "incorrect" advice when she advised to use a defibrillator instead of commencing CPR.
She told the inquest there was further "confusion and unnecessary delay" in the first aid provided because some school staff did not know much about Lucas's medical conditions and suspected he was having a seizure, despite him never having had one.
"It is [to] their credit, in my submission, that they took it upon themselves to undertake this task."
Ms Roper asked the coroner "to consider making a recommendation that the education department review its procedures for obtaining information about medical conditions suffered by its students" and to ensure that teachers received that information "in a timely fashion".
"The inquest has brought to light the difficulties experienced by public schools in obtaining the necessary information about special needs children and extra funding for their care and education," she said.
