Coroner's Finding: Latouche Mazzei, Lucas

Contributing factors

• inadequate supervision during critical time period
• uncut nectarine with stone accessible to child
• child's known tendency to overfill mouth and overeat
• teacher's brief absence from classroom
• education support officer in internal office with restricted view of classroom
• documented need for 1:1 supervision not being met
• negative pressure pulmonary oedema
• poor mobile phone reception in classroom affecting emergency communication
• difficulty with landline phone proximity during emergency

Coroner's recommendations

1. Department for Education must review policy and procedures for obtaining and sharing information about students with special needs to enable teaching staff awareness of care requirements, with reference to practices at Catholic Education South Australia and St Patrick's Special School
2. All teaching staff must be required to hold up-to-date qualifications in providing first aid assistance in an education and care setting
3. First aid guidelines for choking emergencies must be reviewed and amended to reflect Australian Resuscitation Council guidelines, particularly regarding actions when the person becomes unresponsive
4. All telecommunication equipment for teaching staff must be portable to allow the device to be taken by first aid responder to the person in distress
5. Department's policy and procedures must be reviewed and amended for safe storing and consumption of food and drinks within educational sites
6. Minister for Health and Wellbeing should urge the Australian Committee of the International Academies of Emergency Dispatch to update Pro Q/A software procedures for choking to be consistent with Australian Resuscitation Council Guidelines
7. SA Ambulance Service must review training and procedures to be consistent with Australian Resuscitation Council Guidelines, particularly regarding use of Heimlich manoeuvre on children