Finding into death of Nathan Fazal Francis

Contributing factors

• failure to cross-reference medical information against food contents
• random distribution of ration packs without allergy consideration
• inadequate familiarisation of staff with EpiPen administration despite prior training
• 10-minute delay before first EpiPen administration
• co-existing unstable asthma as a risk factor
• remoteness of camp location from intensive medical facilities
• lack of spare EpiPen in first aid kit
• medical information not provided to volunteer medical officer prior to camp

Coroner's recommendations

1. Department of Education and Early Childhood Development to review the 2006 Anaphylaxis Guidelines for Victorian Government Schools to ensure content reflects current best practice and includes requirements of Ministerial Order No. 90
2. Department of Education and Early Childhood Development to provide specific guidance to all schools regarding purchasing of spare or back-up adrenaline auto-injection devices for first aid kits, considering number of diagnosed children and likely availability in various settings including excursions and camps
3. Minister for Education to introduce requirement for all schools to complete an Anaphylaxis Risk Management Checklist on annual basis to ensure ongoing compliance with Ministerial Order No. 90, or alternatively, include detailed checklist in revised Anaphylaxis Guidelines
4. Scotch College to revise student action management plans to incorporate strategies to prevent exposure to allergens in both in-school and out-of-school settings as required under Ministerial Order No. 90, with annual review by school together with parents/carers