Kilvington Grammar School and World Challenge Expeditions plead guilty at County Court over student Lachlan Cook’s death in Vietnam
A “red flag” would have been raised sooner about a student’s “urgent” and ultimately fatal illness while on an overseas school trip if his diabetes had been communicated earlier.
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A Melbourne private school and an international tour company have apologised after a “kind” and compassionate” young student died on a trip to Vietnam in 2019.
Kilvington Grammar School, based in Ormond, and UK-based World Challenge Expeditions Pty Ltd faced County Court on Wednesday over the death of 16-year-old student Lachlan Cook as a result of a medical episode he suffered overseas.
The court heard that in September 2019, a group of Year 10 Kilvington Grammar students, including 16-year-old Lachlan Cook, went on a three-week school trip to Vietnam organised by tour group World Challenge and attended by two Kilvington staff members.
During the excursion, Lachlan developed complications from his Type 1 diabetes, initially thought to be the result of something he ate, and was taken to hospital.
He suffered a cardiac arrest and was resuscitated but remained in a coma until doctors in Melbourne doctors confirmed he was brain dead.
Lachlan’s life support was turned off on October 4, 2019 at the Royal Children’s Hospital.
The court heard that World Challenge got two medical clearance forms for Lachlan prior to the trip – a questionnaire and a medical management form.
While Kelvington had diabetes policies in place for school camps, those policies did not extend to the Vietnam trip, and the school did not bring its “action plan” specific to Lachlan on the journey.
World Challenge did, however, tell Kelvington Grammar before the students’ departure on September 19 that it had looked after the medical aspects of the trip itself and did not require the school’s personal information forms.
The World Challenge expedition leader on the trip — a qualified outdoor educator — spoke with Lachlan about his diabetes once they had left, and Lachlan explained how he self-managed his condition.
His blood glucose levels were discussed each day, and he reported they were “good” or “fine”.
However, while in Hoi An, Lachlan informed the leader that he had vomited and was having trouble keeping down liquids.
He believed he was afflicted by something he ate, and one of the teachers on the trip was also feeling unwell.
While Lachlan was ill, he was given small sips of water and Sprite, continuing to assert his glucose levels were appropriate.
But in the city of Hue, Lachlan complained of thirst and sore ribs.
The expedition leader got in touch with her company’s operations centre and was told by an employee who did not know about Lachlan’s diabetes to give him Hydralyte, which contains glucose.
It was only afterwards she messaged the centre: “I just want to check nothing of what I’m doing changes due to his diabetes.”
Her message, sent through Viber, was not seen for four hours, and a reply advising about dehydration in diabetics came through when the leader herself was asleep.
The worker at the operations centre could not get in touch with the leader before finishing his shift.
Upon becoming aware of Lachlan’s diabetes, he internally reclassified the situation to a higher level of severity, indicating it required professional medical review or the use of prescription medicine, and marking it “urgent” during a shift handover.
The man later said the diabetes would have raised a “red flag” with him immediately if he had known about it earlier.
A teacher on the trip then phoned Lachlan’s mother, and the expedition leader began measuring Lachlan’s blood sugar and heart rate every half-hour.
He complained of fast breathing and vomited again after drinking water.
Appearing to improve, Lachlan went to bed, saying he would wake up if his glucose levels got too high or too low and would seek help if needed.
At 5am the next morning, he told a teacher who went to check on him that he had low energy, and his speech became slurred.
He was given water and Sprite, his glucose levels remaining high.
The expedition leader was woken, and when she checked on Lachlan, he became unresponsive, still able to squeeze her hand and sit up, but not stand.
A taxi was called to take him to hospital, where he stopped breathing and was treated with CPR and a defibrillator.
The school trip continued, with a teacher staying in hospital with Lachlan.
Both were soon flown to Bangkok, Thailand, and then to Melbourne, where Lachlan died.
A WorkSafe investigation and coronial inquest followed.
World Challenge has since implemented various procedures to make its medical approach more thorough.
It expressed its “deepest condolences” in court, Mr Fletcher making “sincere apologies” on behalf of the company.
Kelvington has also has brought in new policies to do specifically with diabetes.
A statement was read to the court on the school’s behalf, acknowledging the “profound impact” of Lachlan’s death on relatives and the community.
“The school is truly sorry for his loss and is deeply remorseful of the circumstances that led to his death,” it said.
It promised to “honour, acknowledge, and remember” Lachlan.
The court heard Kilvington now has an annual Lachlan Cook award for students who are “kind, compassionate, and considerate of others” – terms with which Lachlan’s mother described her son.
Additionally, the school gym holds a memorial plaque, and its community has raised tens of thousands of dollars for charities, including for diabetes research.
Kilvington Grammar and World Challenge Expeditions, through principal Robert French and managing director Peter Fletcher respectively, pleaded guilty to failing to ensure persons other than their employees were not exposed to health and safety risks.
Judge Angela Ellis expressed her “sincere condolences” to Lachlan’s family and friends for their “very sad and tragic loss”.
The matter will proceed to sentencing on January 29, 2025.
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