The South Australian government has apologised to the family of a five-year-old boy who choked to death on a nectarine stone while at school six years ago.
Lucas Latouche Mazzei was in reception at Henley Beach Primary School when the fatal incident occurred in March 2017, prompting a coronial inquest.
That inquest has now handed down its findings, making multiple recommendations relating to school procedures around first aid, choking emergencies and food storage.
Lucas's parents have condemned the way they had been treated by the Department for Education, saying the process of searching for answers about their son's death had been "extremely hurtful and cruel".
The boy's mother, Daniela Mazzei, made an emotional statement to the media outside the South Australian Coroners Court, taking aim at the "organisational abuse" both parents experienced from the department.
She said Lucas's death "could have been prevented".
"It was clear that the Education Department did not want to know how a young boy died in their care. They were not interested in learning from his death to ensure this never happens again," Ms Mazzei said.
Ms Mazzei said the family's search for answers was "extremely hurtful and cruel", and that their approaches to the department following Lucas's death were "effectively ignored".
"Lucas's death did not receive the attention it deserved from the Education Department, even when we insisted on it," she said.
"[We] ask the Department of Education to acknowledge that Lucas died because something went wrong in one of the special needs classrooms where he was left alone unsupervised."
In response, Education Minister Blair Boyer said he and the department were "prepared to sit down and offer my apologies, and our apologies face to face" with Lucas's parents.
"I want to begin my comments by offering my sympathies to the family, and my apologies as well, for what took place in March 2017 which led to Lucas's very tragic death at the very tender age of five," he said.
"We will do everything in our power to act as swiftly as we possibly can."
Department chief executive Martin Westwell, who was appointed to the position in 2022, said the department's response was "clearly inadequate".
"This is not the sort of Department for Education we want today," he said.
"I want to apologise for the department’s response, that was clearly inadequate.
"We've reached out to talk to the family to offer our apologies … especially for the grief and hurt that was caused by the lack of that interaction, the lack of reaching out from the department, earlier on."
Ms Mazzei said Lucas's family still celebrates his birthdays, and places his handcrafted star on its Christmas tree every year.
"We talk about him to his siblings but our grief will always be with us. His death could have been prevented."
Inquest recommends review of information sharing protocols
On the day he died, Lucas's classmates had gone to a science lesson, but he was left behind because he was deemed at risk of putting dangerous substances into his mouth due to his developmental delays.
Lucas was left unsupervised for up to 10 minutes in his classroom, and was watching his favourite cartoon The Gruffalo.
The inquest, which delivered its findings on Friday, concluded that he had obtained the nectarine "without being noticed" and that he "silently choked on the nectarine's stone".
Despite a "series of frantic attempts to save" his life, he was unresponsive in the ambulance that was rushing him to hospital.
The coronial inquest, which began last year, heard Lucas required one-on-one support "at all times" and needed help with eating because he could not recognise when his mouth was full.
Deputy state coroner Ian Lansell White made a number of recommendations, calling on the Department for Education to review its policies and procedures for "obtaining and sharing information" about students with "special needs and or medical conditions".
He said all teaching staff should hold up-to-date first aid qualifications, and urged that "guidelines for a choking emergency are reviewed and amended to reflect those of the Australian Resuscitation Council, in particular concerning a first responder's actions if the person choking becomes unresponsive".
At the time of Lucas's death, there was no portable landline phone in the classroom, which meant staff had to make a triple-0 call on a mobile phone in an area that was known to have poor reception.
Mr White recommended that "telecommunication equipment for teaching staff be portable", and that the Education Department update its policies to ensure food is safely stored at schools.
The deputy coroner also recommended that the state's Health Minister direct the SA Ambulance Service to align its training and procedures with the Australian Resuscitation Council Guidelines, and review whether the Heimlich manoeuvre should be recommended to a first responder.
In a statement, Health Minister Chris Picton said that SA Health would review the findings and ensure any necessary changes were made.
The Education Minister has said he is also working through the recommendations.
"There are very clear findings in here about things that weren't done properly and that things were unacceptable," Mr Boyer said.
"These are all things we want to do, we just need … to look at how we can operationalise all this stuff and get it into place in our schools.
"I want to do everything we can so that what happened to Lucas can't happen to anybody else."
Mr Westwell said the Education Department would "look really closely at these recommendations" and "would respond to them appropriately".
He said the department had already implemented several other changes in response to the case.
"Since these events, we've updated a number of policies and procedures, so in particular things like our duty of care," he said.
"Importantly, we updated our … eating and drinking policy as well."
