The World Challenge trip leader had a conversation with Lachlan about checking his blood glucose levels during the night and Lachlan said if his levels got too high or low he would wake up and adjust them or ask for help.
Jamieson found that Lachlan was generally capable of managing his diabetes adequately on his own,but he should not have been expected to self-manage when it was apparent he was unwell.
A Kilvington Grammar teacher checked on Lachlan at 5am the following morning,and while he was initially coherent,Lachlan said he had no energy and started to slur his speech.
The teacher found his blood glucose levels were high,and after checking again two minutes later,went to wake the World Challenge trip leader.
“Shortly after (the trip leader) attended Lachlan’s room,he became verbally unresponsive,his body became floppy and he was not able to stand,” Jamieson said.
He was taken to hospital,where the teacher used Google Translate on his mobile,to try to explain Lachlan’s condition to staff.
Lachlan was moved to intensive care but had a cardiac arrest and was flown by air ambulance to the Royal Children’s Hospital,where he was declared brain-dead and taken off life support.
Jamieson found Lachlan died from hypoxic-ischemic encephalopathy,a type of brain damage,due to the complication from his diabetes.
“The circumstances I find were easily avoidable and rectifiable before he lapsed into extremis,” she said.
“Having considered all the evidence and applying the requisite standard of proof,I find that the death of Lachlan McMahon Cook was preventable,and his death was a tragedy to all who knew and loved him.”
In a statement,Lachlan’s family said:“Today we learned that the death of our son and brother was preventable. To say this is heartbreaking defies the pain that this news causes.”
They said they could only hope that other schools and camp providers learned from their experience,and that people who accompanied children on school activities were vigilant and well-trained by their employers.
“You care for our children in our absence,” the statement said. “All families should have confidence that when their children participate,that they will return back home,and into their arms,healthy and safe.”
Kilvington Grammar said “the findings were,as expected,very challenging and difficult listening,and we are grateful to the coroner for the rigour and thoroughness of the inquest.”
The school said it had implemented several restorative practices since 2019 and would continue to apply these to ensure the safety of students both domestically and internationally.
“The thoughts and prayers of the Kilvington community are with the Cook family following the coroner’s findings today as they continue to grieve the loss of their son,Lachlan,” the school said in a statement.
World Challenge said its enduring thoughts had been with Lachlan’s family and friends since 2019.
“We constantly review and update our health and safety procedures and will continue to do so as we implement the final recommendations from the coroner,” it said in a statement.
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