A young Adelaide boy with special needs choked on a nectarine stone while at school, with an inquest into his death to examine the competency of first aid provided by staff.
Five-year-old Lucas Latouche Mazzei died in March 2017 after choking on the stone at the Henley Beach Primary School.
He had been watching a cartoon at the time with a teacher moving between the classroom and an office.
Counsel sssisting Emma Roper told the inquest on Monday that when Lucas was noticed to be choking, staff stood him up and started banging his back to try to clear his airway.
By this time he had begun to turn blue around his lips and cheeks.
Staff also tried lifting him up by his legs so he was upside down as they slapped his back.
A defibrillator was retrieved but was unable to be used while CPR was not commenced until paramedics arrived.
Ms Roper said it appeared the provision of first aid in accordance with the instructions provided by the triple-zero operator was hampered by panic and communication difficulties, including problems with mobile phone reception.
"For whatever reason, it took almost two minutes for the triple-zero operator to establish that Lucas was not breathing," she said.
"A further minute passed before instructions for rescue breathing were given. CPR did not in fact commence until the arrival of the first ambulance."
Ms Roper told Deputy State Coroner Ian White that there was no doubt that those who performed first aid on Lucas did so to the very best of their ability, in what was "undeniably an acutely stressful situation".
"What this inquest will explore is whether teachers in the public school system are receiving sufficient training in the provision of first aid," she said.
"To put it another way, this court will consider whether teachers in public schools are properly equipped to respond to a first aid emergency should the need arise."
Under current rules, permanent teachers in SA public schools are not required to have first aid qualifications
Ms Roper said the inquest would also consider if Lucas had been adequately supervised before his death.
The boy was diagnosed with a rare genetic disorder and had global developmental delays.
He was also known to put "anything and everything" in his mouth.
The inquest continues.
