Lachlan Cook was a student at Kilvington Grammar School who went on a three-week overseas school trip to Vietnam organised through World Challenge Expeditions during the 2019 September holidays. He first heard about the trip in March 2018. In April and May 2018, he attended presentations by a lady from World Challenge for students and their parents, giving information about the trip. This included that there was 24/7 access to a doctor of any medical specialty or to an in-country support team. This was important for Lachlan and his parents as he'd been diagnosed with Type 1 Diabetes when he was 9. He'd learnt how to self-manage his diabetes, monitor his own blood glucose levels and use an Insulin Pump.
Because of his diabetes, Lachlan saw his GP in June 2019 for a review of his fitness to attend the trip. The GP looked at World Challenge's Medical Questionnaire Information Sheet and completed the Diabetes Questionnaire form.
Lachlan and other students were also involved in pre-trip planning sessions, but a planned training weekend was cancelled due to bushfires in Victoria. Instead, there was a preparation day at the School but the World Challenge expedition leader was unable to attend.
On 25 September 2019, after several days travelling in Vietnam, Lachlan and the group arrived in Hoi An. They explored the markets and ate street food. The next morning, Lachlan told the Expedition Leader, Ms Walsh, that he'd vomited twice that morning and couldn't hold down any liquid. He thought it was something he'd eaten the night before. One of the two teachers on the trip (let's call her Sue) was also unwell so she and Lachlan stayed at the hotel while the others went out.
At about 10 am, they all took a bus from Hoi An to Hue. During the trip, Lachlan became unwell, vomiting twice. He was asked about his blood glucose levels and replied that they were okay, before moving to the front of the bus so that Ms Walsh could monitor his fluid intake. He continued to say that his blood glucose levels were okay when asked during the trip.
At about 2 pm, after arriving in Hue, Ms Walsh did some further testing on Lachlan, taking his heart rate and temperature. He and Sue stayed in their rooms while the rest of the group, including another teacher (let's call him Greg), went to the local market.
At about 5 pm, Lachlan woke up with abdominal pain. He told Sue who rang the other group leaders and asked them to return to the hotel. Lachlan had started vomiting and was complaining about being thirsty. He drank more fluid but continued to vomit and complained of sore ribs. Ms Walsh monitored his fluid intake and tried to get him to take Panadol for his pain. Greg was concerned about Lachlan's condition and suggested that they ring the World Challenge Operations Centre, or a doctor for advice.
Ms Walsh called the Operations Centre and was told to continue with her current treatment, monitoring Lachlan's fluid intake and getting him to rest. The Operations Centre told her that if his vomiting continued, she was to give him a nausea medication.
At about 7 pm, Greg telephoned Lachlan's mother to tell her that Lachlan was unwell. Greg told her that Lachlan's blood glucose levels were "21" and she said that she didn't want his levels any higher and that they should be checked every half hour.
Greg asked Lachlan the level at which they should be worried about his blood glucose levels, and Lachlan replied, "25 plus". Ms Walsh began taking his blood glucose levels, heart rate and temperature every 30 minutes and his levels dropped to 17 and stayed there for all half hourly tests until 9.45 pm.
A bit later, Lachlan was alert and moving around the room but was complaining of "fast" breathing and indicated that his pain hadn't subsided. A short while later, he vomited again. Ms Walsh gave him the nausea medication, and, about 30 minutes later, he said he felt better. He indicated his pain had subsided, he was calmer and was breathing better. Ms Walsh talked to him about checking his blood glucose levels during the night and he said that, if they got too low or high, he'd wake up and adjust them, or get Ms Walsh for help. She left him a small amount of water so that he wouldn't drink excessively during the night.
At about 5 am, Greg went to check on him. He was seated on the end of his bed, breathing fast, but was initially coherent and communicating. Lachlan indicated he'd slept most of the night and didn't vomit and then laid back as if he was going back to sleep. Greg asked him to take his blood glucose levels and gave him a small amount of water to drink. Lachlan said he had no energy and his speech started to slur. Greg gave him a small amount of Sprite and checked his blood glucose level. It was 27+. Greg asked Lachlan what to do and Lachlan replied that he should check the reading again in 10 minutes. Greg re-checked Lachlan's levels in 2 minutes. As it was still 27+, Greg woke up Ms Walsh who went to Lachlan's room where she found him verbally unresponsive, his body floppy, and unable to stand. They took him to Hue Hospital Emergency Department, where Greg, using Google Translate on his mobile, tried to tell the staff about Lachlan's condition. He was moved to the Intensive Care Unit, but he suffered a cardiac arrest. The next morning, he was flown to Bangkok Hospital in Thailand. There'd been little improvement in his condition.
Lachlan's family travelled to Thailand to be with him. He remained in Bangkok Hospital until 2 October 2019, when he was flown to the Royal Children's Hospital in Victoria arriving there on 3 October 2019 but, the next day, he was declared brain dead. His life supports were removed, and he died soon after.
Because Lachlan died in Victoria, his death became the subject of a coronial investigation. Sadly, many deaths of students involved in offsite activities end up being investigated by the Coroner whose task is to make factual findings about the manner and cause of death. In other words, the Coroner's role is to find out what happened. It's not to decide if someone has a civil liability. The Coroner shouldn't make a finding that appears to decide civil liability. Nevertheless, many Coroners' reports do "point the finger" at people whose actions or omissions have let the deceased student down.
The Coroner looking into Lachlan's death certainly did this. She felt that the School should have done more and couldn't rely on World Challenge staff alone. For example, she found that the School and World Challenge failed:
- to ensure that their staff had the requisite training and skill set to care for the children under their care while on an overseas school trip – no-one had specific training around diabetes management, the potential impact of other illness to a person with diabetes, or sufficient familiarity with the relevant symptoms; and
- to get together with Lachlan, his family and their medical team before the trip to share information about his condition and how to manage it – this would have provided the intelligence the supervising adults on the trip so clearly lacked.
The Coroner also found that the School staff made assumptions about the level of medical knowledge of the World Challenge Expedition Leader and the access to medical support and their own roles, without doing very much to inform themselves of their actual responsibilities and what they should have been aware of in relation to Lachlan's condition.
The School also failed to give World Challenge the detailed Action Plan for managing Lachlan's Type I diabetes that was at the School. This meant that World Challenge didn't ensure its staff had all relevant documents about Lachlan's openly disclosed medical condition and, therefore, a significant opportunity was lost to the staff to have the information that would have enabled them to act in an informed and timely way to the onset of Lachlan's illness.
The Coroner made this rather damning comment:
"I cannot accept that Kilvington Grammar School's teachers could expect World Challenge to have full responsibility for the welfare of the students regardless of how World Challenge promoted the trip or what assurances about supports and backups they had – Kilvington Grammar School teachers were present, their trips were paid for by World Challenge, but they were not on holiday. Kilvington Grammar School should have ensured that their teachers were well equipped to independently support their students."
The consequences of this tragic death are huge: a family grieves the loss of a son and sibling; teachers feel the guilt of not doing enough; the School has pleaded guilty to charges in the Melbourne Magistrates' Court under the Occupational Health and Safety Act 2004 (VIC); World Challenge is also facing charges; and there is still the possibility of a civil claim for damages against them both.
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