Five-year-old boy’s death after eating nectarine at school could have ‘been prevented’

The parents of a five-year-old boy who tragically died after choking on a nectarine at school have slammed the Education Department.

A five-year-old boy’s death after choking at a South Australian school could have been prevented if he was better supervised, a coronial inquest has found.

And the parents of the child have claimed the Education Department perpetrated “ongoing organisational abuse” to protect its reputation following the death of their beloved boy.

Lucas Latouche Mazzei died after eating a nectarine at Adelaide’s Henley Beach Primary School in March 2017.

An inquest into his death was started in November 2021 and SA Deputy Coroner Ian White handed down his findings on Friday.

Lucas was born with a rare genetic condition known as SSADH which only affects 350 people worldwide and leads to developmental delays.

Lucas Latouche Mazzei died on March 27, 2017 after choking on a nectarine stone in a special education classroom at Henley Beach Primary School. Picture: Supplied to SA Coroner

On the day of his death, the young boy was being supervised separately from his special needs class by his home room teacher and education support officer as he was not participating in a science lesson. This was due to the risk of him putting objects in his mouth.

His teacher left the classroom briefly and the education support officer was in an internal office with a restricted view of the area where he was sitting watching a movie.

Without being noticed, he found a nectarine in the classroom and silently choked on the fruit’s stone while watching his favourite cartoon character The Gruffalo.

Mr White found Lucas’ death “would have been prevented” that afternoon if the staff had remained in the classroom at all times while he watched the film.

The special needs classroom. Picture: SA Police / SA Coroner

The home room teacher noticed something was wrong when she returned.

Staff rushed to help Lucas and emergency services were called on a landline phone in the office which could not reach those helping Lucas. The SA Ambulance Service called back a mobile but the classroom was known to have poor mobile phone reception.

Paramedics arrived and Lucas was taken to the Women’s and Children’s Hospital where he was declared dead.

Mr White recommended the Education Department review its policy and procedures around information concerning students with special needs and/or medical conditions, and that all teaching staff are required to have up-to-date classroom-specific first aid training.

He also recommended all classroom phones are portable so they can be taken to a person in distress, and that the department’s policy and procedures on storing food are reviewed.

An ‘L’ marks where Lucas sat watching his movie on the classroom smartboard. Picture: SA Coroner

The school sent out a newsletter the week after Lucas’ death saying he had died “from complications after an isolated medical episode related to his condition”, which Mr White said was inaccurate and added distress to Lucas’ parents.

The school also placed a plaque outside the classroom acknowledging Lucas’ death without consulting the parents.

Speaking to media outside the Coroner’s Court on Friday, Lucas’ mother Daniela Mazzei said the department did not want to know why a young boy had died in their care or learn from the incident to ensure it does not happen again.

She claimed the department’s “ongoing organisational abuse” to protect its reputation added to their grief.

Ms Mazzei said they were led to believe the department was conducting an independent investigation after Lucas’ death when it wasn’t.

“We have been looking for answers since the day Lucas died. The journey has been extremely hurtful, even cruel,” she said.

“We ask the Department for Education to acknowledge that Lucas died because something went wrong in one of their special needs classrooms where he was left alone unsupervised.”

Mr White described the department’s relationship with Lucas’ parents as “problematical”.

SA Education Minister Blair Boyer. Picture: Emma Brasier

SA Education Minister Blair Boyer apologised for what took place in March 2017 in a press conference following the release of Mr White’s findings.

“We’ll do everything in our power to act as swiftly as we possibly can on the coronial inquest and the findings from that coroner’s report,” he said.

He said he had also reached out to the family’s barrister and asked for an opportunity to apologise to Lucas’ parents face-to-face.

Education Department chief executive Martin Westwell said the inquest findings were “heartbreaking” to read.

“I know the family have been critical of the department as well and I want to apologise for the department’s response that was clearly inadequate and wouldn’t happen under my leadership,” he said. “This is not the sort of department for education we want today.”

Mr Westwell said some relevant changes to policies had already been made and further changes would be made.

Mr Boyer and Mr Westwell were not in their current positions in 2017.