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Finding into death of Lachlan McMahon Cook

Deceased

Lachlan McMahon Cook

Demographics

16y, male

Coroner

Coroner Audrey Jamieson

Date of death

2019-10-04

Finding date

2023-12-20

Cause of death

Hypoxic/ischaemic encephalopathy in the context of diabetic ketoacidosis

AI-generated summary

A 16-year-old with Type 1 Diabetes died from diabetic ketoacidosis (DKA) precipitated by acute gastroenteritis acquired while on a school trip to Vietnam. Despite reporting vomiting at 8am on 26 September 2019, Lachlan was treated conservatively as gastroenteritis for 24 hours without blood glucose or ketone testing, without escalation to medical support, and without reference to his Diabetes Action Plan. He deteriorated over this period and arrested from severe DKA. Critical failures included: neither school nor expedition staff had diabetes-specific training; the school's detailed Diabetes Action and Management Plans were not provided to staff or World Challenge; World Challenge's Operations Centre call-taker was not informed of Lachlan's diabetes despite receiving a call about him; no pre-trip coordination meeting occurred between family, school, medical team and expedition organisers; and Lachlan was expected to self-manage his condition while acutely unwell despite cognitive impairment from hyperglycaemia. The coroner found the death was preventable through proper information sharing, staff training, and escalation protocols.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

endocrinologygeneral practiceintensive carepaediatricsemergency medicine

Error types

diagnosticcommunicationsystemdelay

Drugs involved

insulinparacetamolondansetroninsulinnovorapid

Clinical conditions

type-1 diabetes mellitusdiabetic ketoacidosishypoglycaemiahyperglycaemiagastroenteritiscardiac arresthypoxic ischaemic encephalopathybrain death

Procedures

insulin pump managementblood glucose monitoringketone testing

Contributing factors

Failure to recognise vomiting as a diabetic emergency requiring blood glucose and ketone testing
Absence of diabetes-specific training for supervising adults on the expedition
Failure to provide school's Diabetes Action Plan and Management Plan to expedition staff
Failure to share Lachlan's diabetes diagnosis with World Challenge Operations Centre call-taker despite receiving a call about him
Inadequate communication between World Challenge Operations Centre and expedition leader regarding Lachlan's medical condition
No pre-trip coordination meeting between school, family, medical team and expedition organisers
Reliance on adolescent to self-manage diabetes while acutely unwell with cognitive impairment from hyperglycaemia
Suboptimal glycaemic control prior to travel placing Lachlan at increased risk of DKA
Acute gastroenteritis acquired while travelling acting as precipitant of DKA
Delay of approximately 24 hours before hospital presentation

Coroner's recommendations

World Challenge Expeditions create and implement a policy directed at improving communication and the sharing of information with schools they are engaging with
World Challenge Expeditions through its revised communication and information sharing policy ensure that they access the respective school's Action and Management Plans for students attending their expeditions and enhance the information they hold on students with medical conditions by holding pre-trip meetings with trip leaders, attending teachers, parents, a member of the child's medical treating team or the school nurse, and the student
World Challenge Expeditions update the Leader's Manual and pre-trip training material to include information about diabetes, hypoglycaemia, hyperglycaemia, ketone testing and safe levels of blood glucose levels
World Challenge Expeditions ensure that medical clearance to attend an expedition is obtained from the student's specialist, if the specialist is attended on a regular basis

Full text

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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

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