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 — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Rule 63(1)
IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2019 5395
FINDING INTO DEATH WITH INQUEST Form 37 Rule 63(1) Section 67 of the Coroners Act 2008 Inquest into the death of: LACHLAN McMAHON COOK Findings of: AUDREY JAMIESON, CORONER Delivered On: 20 December 2023 Delivered At: Coroners Court of Victoria 65 Kavanagh Street, Southbank 3006 Hearing Dates: 21 March 2022 – 25 March 2022, 28 March 2022 and 16 June 2022.
Appearances: Mr Andrew Woods of Counsel on behalf of Kirsten McMahon and Peter Cook (Brave Legal) Mrs Mary Anne Hartley QC leading Ms Dianna Costaras of Counsel on behalf of Kilvington Grammar School (Moores) _______________________________________________________________________ 1 of 64
Ms Fiona Ryan SC leading Ms Stella Gold of Counsel on behalf of World Challenge Expeditions (G C Legal) Mr Morgan McLay of Counsel on behalf of Dr John Croatto (Avant Law) Ms Fiona Ellis of Counsel on behalf of Dr John Welch (Ball + Partners) Counsel Assisting the Coroner: Leading Senior Constable Danielle Lord, Police Coronial Support Unit _______________________________________________________________________ 2 of 64
TABLE OF CONTENTS Training and knowledge of diabetes management of the Kilvington Grammar School The sufficiency of documentation available to trip staff that recorded Lachlan’s The understanding of Lachlan’s specific condition and needs if he became unwell The adequacy of communication support for the teachers and expedition leader while Concurrent Evidence – Expert Panel: Dr Mark Overton, Professor Geoffrey Ambler _______________________________________________________________________ 3 of 64
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I, AUDREY JAMIESON, Coroner having investigated the death of LACHLAN McMAHON
COOK AND having held an Inquest in relation to this death on 21 March 2022 – 25 March 2022, 28 March 2022 and 16 June 2022 at the Coroners Court of Victoria, 65 Kavanagh Street, Southbank 3006 find that the identity of the deceased was LACHLAN McMAHON COOK born on 26 May 2003 died on 4 October 2019 at the Royal Children’s Hospital, 50 Flemington Road, Parkville 3052 from: 1 (a) HYPOXIC/ISCHAEMIC ENCEPHALOPATHY IN THE CONTEXT OF
DIABETIC KETOACIDOSIS In the following summary of circumstances: Lachlan McMahon Cook, a student at Kilvington Grammar School, was travelling overseas in Vietnam, participating in a school trip organised through World Challenge Expeditions, when he suffered a cardiac arrest precipitated by severe ketoacidosis. He was subsequently repatriated to the Royal Children’s Hospital in Melbourne but died soon after from nonsurvivable brain injury.
Lachlan McMahon Cook1 was born on 26 May 2003 and was 16 years of age at the time of his death. He was the much-loved son of Kirsten McMahon (Ms McMahon) and Peter Cook (Mr Cook). Lachlan was the youngest of two children to the couple, Lachlan having an older sister, Isabelle.
In April 2012, at the age of 9 years, Lachlan was diagnosed with Type 1 Diabetes. As he grew older, he was managed by various staff at the Monash Medical Centre with 1 At the request of his family, Lachlan McMahon Cook was referred to as “Lachlan” only throughout the Inquest. For consistency, I have also referred to him as Lachlan throughout the Finding, save for where formality requires me to use his full name.
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Paediatric Endocrinologist Dr John Welch (Dr Welch) overseeing Lachlan’s condition in recent years, seeing him at 3-monthly intervals.
Lachlan had learnt how to self-manage his diabetes, monitoring his own blood glucose levels and how to utilise an Insulin Pump.
Lachlan attended Kilvington Grammar School in Ormond, Victoria. He was a hardworking student and was also involved in multiple sporting activities.
Preparation for the school trip
On 29 March 2018, Lachlan received a letter advising him of a forthcoming 3-week school trip to Vietnam, to be run by World Challenge Expeditions (World Challenge) during the 2019 September holidays.
On 24 April 2018, Michelle Lionello (Ms Lionello) from World Challenge did a short presentation at Kilvington Grammar School to generate interest amongst the year 9/10 group.2
On 3 May 2018, Ms Lionello did a longer presentation to interested students and their parents which included details of the itinerary, costs, administration, and general details about the backup and supports available while students are on the trip including information on the World Challenge Operations Centre,3 Healix International Medical Support (Healix)4 and that it provided 24/7 access to a doctor of any medical speciality or to an in-country support team.5
Lachlan, who had never travelled to Asia before was pleased of the opportunity to attend the trip and began saving and committing to part-time work to raise the money required.
2 Exhibit 10 – Statement of Michelle Lionello dated 11 November 2021.
3 The Operations Centre utilises a bespoke piece of software, called HOTH for providing administrative and minor medical issues advice.
4 Healix International offers healthcare assistance and risk management solutions to companies and individual consumers, typically as part of their travel insurance policy. World Challenge has a direct policy and wider partnership with Healix International to provide medical support and risk management services.
5 Ibid, Transcript of Proceedings (TP) at page 226.
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Due to his pre-existing medical condition Type I Diabetes, Lachlan attended his general medical practitioner (GP) Dr John Croatto (Dr Croatto) on 29 June 2019, who reviewed Lachlan’s fitness to attend the overseas trip. Dr Croatto reviewed World Challenge’s Medical Questionnaire Information Sheet and completed the Diabetes Questionnaire form responding to questions posed.
Lachlan and other students were also involved in pre-trip planning sessions, but a planned training weekend was cancelled due to bushfires in Victoria. A ‘build up day’ was held and convened by Ms Lionello6 from World Challenge’s sales team, as the planned Expedition Leader, Anna Walsh (Ms Walsh), was unable to attend. At ‘build up day’ the Kilvington Grammar School teachers going on the trip also attended and students brought their bags/kit, everything they were required to take and any medical equipment or medication. In a conversation with Ms Lionello and teachers Teacher 1 and Teacher 2, Lachlan was asked about his diabetes management and medication.
On 14 September 2019, Lachlan flew to Vietnam with the Kilvington Grammar School group, which included teachers Teacher 1, Teacher 2 and World Challenge Expedition Leader, Ms Walsh.
On 25 September 2019, after several days travelling in Vietnam, Lachlan and the group travelled by train and bus from Nha Trang to Hoi An. The group spent the morning at their hotel before exploring Hoi An, and later that evening, the group went out into the local area, exploring the markets and eating street food.
On 26 September 2019, at approximately 8.00am, Lachlan and the group met in the hotel lobby. Lachlan advised Ms Walsh that he had vomited twice that morning and could not hold down any liquid. Lachlan said that he thought it was something he had eaten the night before. Teacher 2 was also feeling unwell, stating she was feeling dizzy and nauseous. Teacher 2 and Lachlan both stayed in their rooms at the hotel whilst the rest of the group went out for breakfast.
6 Ms Lionello held a basic Fist Aid Certificate, including CPR training, which she updated yearly – TP at page 240, Coronial Brief (CB) at page 825.
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During the trip Lachlan became unwell, vomiting twice. Lachlan 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. Ms Walsh gave Lachlan some water, but as he was complaining of having no energy, she gave him small amounts of the soft drink, Sprite. Lachlan continued to say that his blood glucose levels were okay when asked during the bus trip.
Lachlan and Teacher 2 then stayed in their rooms while the rest of the group, Teacher 1, Ms Walsh and the remaining seven students, went to the local market at approximately 4.00pm.
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 Lachlan to take dissolvable Panadol for his pain, however Teacher 1 was concerned about Lachlan’s condition and suggested that they ring the World Challenge Operations Centre (WCOC), or a Doctor for advice.
Ms Walsh called the WCOC and was advised to continue with her current treatment, monitoring Lachlan’s fluid intake and getting him to rest. WCOC told Ms Walsh that if Lachlan’s vomiting continued, she was to give him the medication, ‘Ondansetron’ for nausea.
At approximately 7.00pm, Teacher 1 telephoned Lachlan’s mother Ms McMahon, to advise her that Lachlan was unwell. Teacher 1 says he told Ms McMahon that Lachlan’s blood glucose levels were “21” and that Ms McMahon responded that she did not want Lachlan’s blood glucose levels any higher and that they should be checked every half hour.
Teacher 1 asked Lachlan the level at which they should be worried about his blood glucose levels, and Lachlan replied, “25 plus”.
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Ms Walsh began taking Lachlan’s blood glucose levels, heart rate and temperature every 30 minutes and Lachlan’s blood glucose levels dropped to 17 and stayed at that level for all half hourly tests until 9.45pm.
Ms Walsh, Teacher 2 and Lachlan stayed at the hotel whilst the rest of the group went out to dinner. When the group returned after dinner, Lachlan was alert and moving around the room but was complaining of “fast” breathing and indicated that his pain had not subsided. Teacher 1 gave Lachlan some breathing techniques and Lachlan started to calm down but a short while later Lachlan vomited after having taken large gulps of water. Ms Walsh gave Lachlan Ondansetron under his tongue, and about 30 minutes later, Lachlan said that he felt better. He indicated his pain had subsided, he was calmer and was breathing better. Ms Walsh had a conversation with Lachlan about checking his blood glucose levels during the night and Lachlan said that if his levels got too low or high, he would wake up and adjust them, or get Ms Walsh for help.
Ms Walsh left Lachlan a small amount of water so that he would not drink excessively during the night.
On 27 September 2019 at approximately 5.00am, Teacher 1 went into Lachlan’s room to check on him. Lachlan was seated on the end of his bed, breathing fast, but was initially coherent and communicating. Lachlan indicated he had slept most of the night and did not vomit and then laid back as if he was going to go back to sleep. Teacher 1 asked Lachlan to take his blood glucose levels and gave him a small amount of water to drink. Lachlan said he had no energy and started to slur his speech. Teacher 1 gave Lachlan a small amount of Sprite and checked Lachlan’s blood glucose levels.
Lachlan’s blood glucose level was 27+.
As it was still 27+, Teacher 1 went to wake up Ms Walsh.
Hue Hospital. The journey took approximately 5-10 minutes, and on arrival at the Emergency Department, Teacher 1, with some assistance from the Application (App) ‘Google Translate’ on his mobile telephone, attempted to convey to staff what was Lachlan’s condition.
After 30 minutes of cardio-pulmonary resuscitation (CPR) and the application of an automated external defibrillator (AED) Lachlan’s circulation returned.
Lachlan remained in the ICU. He was found to be severely acidotic, and Doctors said that his likely diagnosis was Diabetic Ketoacidosis. They also indicated that his neurological condition was poor.
On the 28 September 2019 at approximately 3.30am, Lachlan was transported by aeroplane to Bangkok Hospital in Thailand. There had been little improvement in his condition.
Lachlan’s family, and World Challenge Expeditions Managing Director, Peter Fletcher (Mr Fletcher) travelled to Thailand to be with Lachlan.
Lachlan remained in Bangkok Hospital until 2 October 2019, when he was transported by Air Ambulance to the Royal Children’s Hospital (RCH), Victoria, Australia, for ongoing management, neurological prognostication and brain death testing.7 Lachlan’s family accompanied him home. He arrived at the RCH in the afternoon of 3 October 2019.
On 4 October 2019, following further testing and evaluation while in the RCH Paediatric Intensive Care Unit, Lachlan was declared brain dead. Lachlan’s family consented to organ donation. His life supports were removed, and he died soon after.
Professor Trevor Duke, a consultant in Intensive Care at the RCH at the time of Lachlan’s admission described Lachlan’s death in his statement in the following terms: 7 Statement of Professor Trevor Duke, Acting Director, Paediatric Intensive Care Unit, RCH dated 16 December 2020 – CB at pages 66-67.
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In the event it would assist the Coroner, I think it probable that Lachlan arrested from severe diabetic ketoacidosis, most likely precipitated by a gastrointestinal infection acquired while travelling, on a background of unstable diabetes. It is not uncommon for adolescents to poorly manage their diabetes and be prone to DKA, it is a complicated activity. On a hiking trip in a tropical environment, different eating patterns, non-routine exercise and energy utilization, and inter-current infections make diabetes stabilization even more challenging, and if this care is not closely supervised or occurs in a place where rescue therapy is not easily accessible, such a tragic outcome is possible.8
Specifically, Lachlan’s death was reportable, in that his death was unexpected in the context of his previously managed Type 1 Diabetes.
9 Section 89(4) of the Act.
10 Section 67(1) of the Act.
11 See for example Harmsworth v The State Coroner [1989] VR 989; Clancy v West (Unreported 17/08/1994, Supreme Court of Victoria, Harper J).
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The broader purpose of coronial investigations is to contribute to the reduction of the number of preventable deaths through the findings of the investigation and the making of recommendations by Coroners, generally referred to as the ‘prevention’ role.12 Coroners are also empowered to report to the Attorney-General on a death; to comment on any matter connected with the death they have investigated, including matters of public health or safety and the administration of justice; and to make recommendations to any Minister or public statutory authority on any matter connected with the death, including public health or safety or the administration of justice.13 These are effectively the vehicles by which the prevention role may be advanced.14
It is not the Coroner's role to determine criminal or civil liability arising from the death under investigation. Nor is it the Coroner’s role to determine disciplinary matters.
Section 52(2) of the Act provides that it is mandatory for a Coroner to hold an Inquest into a death if the death or cause of death occurred in Victoria and a Coroner suspects the death was as a result of homicide, or the deceased was, immediately before death, a person placed in custody or care, or the identity of the deceased is unknown. Section 52(2) was not applicable to Lachlan’s death.
Section 52(1) of the Act further provides that a coroner may hold an Inquest into any death that the coroner is investigating. Coroners have absolute discretion as to whether to hold an Inquest. However, a Coroner must exercise the discretion in a manner consistent with the preamble and purposes of the Act. In deciding whether to conduct an Inquest, a Coroner should consider factors such as (although not limited to), whether there is such uncertainty or conflict of evidence as to justify the use of the judicial forensic process; whether there is a likelihood that an Inquest will uncover important systemic defects or risks not already known about and, the likelihood that an Inquest will assist to maintain public confidence in the administration of justice, health 12 The "prevention" role is explicitly articulated in the Preamble and Purposes of the Act.
13 See sections 72(1), 67(3) and 72(2) of the Act regarding reports, comments and recommendations respectively.
14 See also sections 73(1) and 72(5) of the Act which requires publication of Coronial Findings, comments and recommendations and responses respectively; section 72(3) and (4) which oblige the recipient of a Coronial recommendation to respond within three months, specifying a statement of action which has or will be taken in relation to the recommendation.
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services or public agencies.
Section 52(1) was applicable for the holding of an Inquest into the death of Lachlan McMahon Cook.
This finding draws on the totality of the material; the product of the Coronial Investigation into the death of Lachlan. That is, the court records maintained during the Coronial Investigation, the Coronial Brief and further material sought and obtained by the Court, including additional information/submissions received from the Interested Parties, and from Counsel Assisting, Leading Senior Constable Dani Lord.
In writing this finding, I do not purport to summarise all of the evidence but refer to it only in such detail as appears warranted by its forensic significance and the interests of narrative clarity. The absence of reference to any particular aspect of the evidence does not infer that it has not been considered.
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INVESTIGATIONS PRECEDING THE INQUEST Identity
On 4 October 2019, Kirsten McMahon visually identified her son, LACHLAN McMAHON COOK and completed a Statement of Identification.
The identity of Lachlan McMahon Cook was not in dispute and required no additional investigation.
Medical Cause of Death
Coronial Admissions and Enquiries (CA&E) contact log.
E-Medical Deposition Form from the Royal Children’s Hospital.
Post mortem computed tomography (CT) scan.
Post mortem examination
16 Autopsy/Medical Examiner’s Report dated 27 December 2019 – CB at pages 1-11.
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Other special investigations undertaken included tissue taken for histopathology, post mortem CT scan, full toxicology of both antemortem and post mortem samples, urea and electrolytes, creatinine, vitreous glucose, Betahydroxbutyrate, CRP and small and large bowel content for bacteriology and virology. Dr Dodd commented that these investigations identified a small elevation in CRP17 which he said was in keeping with nonspecific inflammatory process, no bacterial pathogens and viruses were detected in the bowel bacteriology and virology and renal impairment was evidence by an elevated urea level although creatinine was not elevated. Both sodium and chloride ions were elevated in keeping with dehydration.
Dr Dodd further commented that the cause of Lachlan’s abdominal pain and vomiting had not been identified by the post mortem examination but would appear to not be related to bacterial or viral infection. He said that it was possible that Lachlan may have reacted to food and possibly had food poisoning but these could not be determined at autopsy.
In his report, Dr Dodd also commented that the download from Lachlan’s insulin pump, which was examined externally from VIFM, appeared to show that the device was operating according to programming and pump by Lachlan.
Toxicology
Forensic pathology opinion
Conduct of my Investigation
17 A substance which is frequently elevated in the presence of inflammation and/or infection.
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INQUEST Direction Hearing/s
Directions Hearings occurred on 27 May 2021, 14 September 2021 and 22 November
On each occasion I was assisted by LSC Lord, PCSU.
Inquest
Viva Voce Evidence at the Inquest18
19 Exhibits 1 – Statement of Kirsten McMahon dated 10 December 2020, Exhibit 2 – Second statement of Kirsten McMahon dated 2 March 2022, Exhibit 3 – Medical Questionnaire Information Sheet, Diabetes Questionnaire (Dr Croatto) and World Challenge Diabetes Medical Management Form (Peter Cook) (Completed Forms), Exhibit 3A – Medical Questionnaire Information Sheet, Diabetes Questionnaire and World Challenge Diabetes Medical Management Form (Blank Forms) and Exhibit 4 – Diabetes Action Plan 2019 – School Setting, signed by Peter Cook and Dr John Welch.
20 Exhibit 5 – Statement of John Croatto dated 20 April 2020.
21 Exhibits 6, 7, 8 and 9.
22 Exhibit 10 – Statement of Michelle Lionello dated 11 November 2021.
23 Exhibit 11 – Statement of Stuart Thomas dated 28 August 2021.
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Teacher 1,24 Teacher, Head of Senior School, Kilvington Grammar School Anna Walsh,25 Outdoor Instructor/Expedition Leader, World Challenge Teacher 2,26 Teacher, Kilvington Grammar School Jon Charlton27 - Principal of Kilvington Grammar School (now retired) Peter Fletcher28 - Managing Director, World Challenge Concurrent evidence of - Dr Mark Overton29
Professor Geoffrey Ambler30
Professor Timothy Jones31
25 Exhibit 16 – Statement of Anna Walsh dated 10 September 2021.
26 Exhibit 17 – Statement of Teacher 2 (with amendments) dated 10 December 2020.
27 Exhibits 18, 19 and 20 – Statements of Jon Charlton dated 8 December 2020 with attachments, 13 September 2021 with attachments (and with amendments) and 19 October 2021 with attachments.
28 Exhibit 21 – Statement of Peter Fletcher and attachments dated 6 December 2020; Exhibit 22 – 2nd statement of Peter Fletcher dated 13 September 2021.
29 Exhibit 13 – Statement/Expert Opinion of Dr Mark Overton dated 28 January 2022.
30 Exhibit 14 – Statements/Expert Opinion of Professor Geoffrey Ambler dated 18 October 2021 & 28 October 2021.
31 Exhibit 15 – Statement/Expert Opinion of Professor Timothy Jones dated 24 January 2022.
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v. The time frame between Lachlan first reporting being unwell, that is, vomiting at 8.00am on 26 September 2019 and his eventual transfer to hospital approximately 24 hours later, hence, should local medical attention have been sought sooner; vi. The apparent reliance on Lachlan to adequately self-manage his diabetes in the circumstances of being unwell and guide staff in his care; and vii. The soundness of the decision to clear Lachlan to travel on this school trip given his diabetes and management and history of the same.
Lachlan’s understanding of his own condition and his ability to self-manage
Ms McMahon provided background information about Lachlan’s diagnosis at age 9 years and his interaction with diabetes educators from that time up until his passing at age 16 years. She explained that the education they received at the outset was intensive and the materials provided extensive. Adam Lamendola (Dr Lamendola) played an important part of this initial education and interacted with Lachlan on a regular basis for the first couple of years and then less frequently on a 4-6 monthly basis. Regular interactions with Lachlan’s endocrinologists – initially Dr Peter Simm (Dr Simm) for the first three years, then Dr Welch, also always involved education about diabetes and how Lachlan was managing it or how he could improve on his management, particularly in the context of him playing sport.
According to Ms McMahon, Lachlan had a great relationship with Mr Lamendola which provided Lachlan with the ability to understand and respect the information flow32 Lachlan learnt to inject his own insulin then progressed to an insulin pump in
The education about how to operate the pump was also extensive of which Ms McMahon said: It’s like a little computer on your body, so – and the education continued to build again with different sets of circumstances.33 32 TP at page 17.
33 Ibid.
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Their relationship was enhanced through a mutual love of sport with their banter about sport enabling Lachlan to open up to talk about his blood sugars. Dr Simm was open about the challenges moving to a pump could bring but Lachlan was keen to understand about the pump as he believed it would make his life better than having injections.34
Lachlan’s relationship with Dr Welch was a different relationship to that with Dr Simm but not because there was any concerns or animosity – it was just different. The education aspect continued with Dr Welch and Ms McMahon said that you could not attend a review without leaning something about the condition – it was integral to the ongoing management.35
Dr Welch also referred to the education Lachlan would have received from Diabetes Nurse Educators when he was first diagnosed at age 9 years and the further education at the time of pump start which he said is actually quite intensive. The further education would have involved education about blood glucose levels consistent with hypoglycaemia and hyperglycaemia and what of the significance of elevated levels that would require him to also test for ketones.36
In 2017 when Lachlan’s pump was upgraded to a Medtronic Pump, no extra education was required about how to operate it according to Ms McMahon although Dr Welch said refresher education would have occurred with a pump upgrade.37 Ms McMahon said there might have been a slightly different functionality, but the fundamentals were the same. However, there were challenging aspects of the insulin pump for Lachlan including the continuous glucose monitoring sensor – as an active person playing a lot of sport the buzzer was going off constantly and he also did not like that he had two sensors taped to his abdomen as they were visible particularly on the basketball court where T-shirts are being taken on and off.38 Consequently, Lachlan moved to a 34 TP at page 19.
35 TP at page 20.
36 TP at page 193.
37 TP at page 194.
38 TP at page 21.
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FreeStyle Libre39 sensor which is placed at the back of the arm, in the subcutaneous tissue, and involved less steps – Lachlan would take his iPhone and utilising the specific App, swipe the sensor on his arm, see what the number was and then enter the number into the pump. He primarily used this method for monitoring his blood glucose but according to Ms McMahon, Lachlan always carried a backup, the fingerprint tester, in case the sensor fell out or he encountered other issues with the method. Because of the fewer steps, the sensor was Lachlan’s preferred method for testing his blood glucose levels. Similarly, Ms McMahon and Mr Cook also had the App on their iPhones which they could have used to monitor Lachlan’s blood glucose levels themselves and/or receive alerts but neither had invoked those features of the App.
Overall, Ms McMahon confirmed that Lachlan always had his own equipment and supplies relating to his diabetes management whether at school or on a camp and was competent to manage his condition and his own pump without supervision when he was well.40
Lachlan’s compliance with reading his blood glucose levels was generally good according to Ms McMahon but he was a teenage boy and sometimes he took too few readings leading to conversations from Dr Welch, herself or Mr Cook along the lines of “That’s not acceptable”.41 But overall, Ms McMahon emphasised that Lachlan did pretty well at managing his diabetes in the circumstances of being a teenage boy: He was a kid who not only was managing all of the intricacies of puberty and becoming a young man, but….with everything that he put in his mouth, every liquid that he drank, every time he ran or did any exercise, even sitting for an exam, he had to translate that into diabetes management.42
In relation to testing for ketones, Ms McMahon recalled that around the age of approximately 13 years,43 there had been three occasions when Lachlan’s blood glucose 39 Which measures interstitial glucose.
40 TP at pages 69 – 70.
41 TP at page 23.
42 TP at page 24.
43 TP at page 28, 88 _______________________________________________________________________ 20 of 64
levels had been high and consistently high44 over approximately two hours necessitating the use of the blood ketone testing strips with the meter – a process that is the same as the glucose testing with the meter but with a different specific strip that provides a range of the level of ketones. On each occasion these instances occurred in the home environment, the ketone testing was done by either Ms McMahon or Mr Cook,45 and Lachlan did not require hospitalisation. Each occasion required constant supervision by one or the other of Lachlan’s parents with the result that a reduction in the blood glucose levels was achieved over a 12 – 14-hour period.46
Dr Welch commented that these three episodes of ketosis experienced early on after Lachlan’s diagnosis was completely normal and the way that it was managed and dealt with by Lachlan’s parents was totally appropriate.47
Lachlan had not had any episodes of hyperglycaemia for approximately 3 years – he had a predisposition for hypos more than hypers according to Ms McMahon.
Consequentially, Lachlan had never had to perform ketone testing himself.48
45 TP at page 89.
46 TP at pages 27 – 28.
47 TP at page 169.
48 TP at page 89.
49 TP at page 73.
50 TP at page 83.
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had to be some flexibility to the interpretation of the reading depending on what was going on at the time of taking it.51
Dr Welch also acknowledged the difficulties of managing adolescents with Type I Diabetes in part he said is due to the amount of physiological change that they are going through. He added that they are growing fast and putting on weight, so physically the total amount of insulin needs to increase as does the amount of insulin you need per kilogram of body weight.52 Three-monthly reviews of these adolescents, including Lachlan, helps to make the necessary adjustments to their insulin dosage after doing downloads from their pumps and checking their haemoglobin A1c’s (HbA1c).53 But Dr Welch also sought to emphasise, as had Ms McMahon, that you are dealing with a child who is trying to develop independence and trying to look after themselves. He said that it is a big ask for anyone to look after their diabetes – kids need to develop those skills to be independent and that’s tricky – add in sport, going out after school, eating take away foods with your mates.54 Nevertheless, Dr Welch said that the absolute minimum number of times per day that Lachlan should test his blood glucose was three times per day and similarly, he would need to give himself boluses three times a day55 after physical activity or certain foods.
The variation in Lachlan’s HbA1c levels did not indicate that his self-management had gone awry according to Dr Welch but that we needed to work on stuff. He said diabetes is constantly changing, moves with time, so the work to be done on levels was working with Lachlan through talking to him about what is going on, motivating him, letting him know when he is doing well – being supportive and encouraging.56 The concern about his levels according to Dr Welch was that we need to adjust things. He did not 51 TP at page 91.
52 TP at page 147.
53 Also known as haemoglobin A1C is a blood test that measures your average blood sugar levels over the past 3 months and is used as a measure to guide treatment to avert chronic complications associated with diabetes, TP at page 148.
54 TP at page 148.
55 TP at page 149.
56 TP at pages 153 – 154.
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however, at the time, have any concerns out of the usual range about Lachlan going on the trip to Vietnam based on the assumptions, that Lachlan had supports available on the trip – medical backup, and somebody on the ground having a good idea of what is going on and what to look for and to actually use the action plan if things need to be implemented.57 Training and knowledge of diabetes management of the Kilvington Grammar School staff
When Lachlan commenced Year 7 at Kilvington Grammar School a Diabetic Action Plan and Diabetes Management Plan was provided to the school. Ms McMahon and Lachlan also provided an education session at the school about Lachlan’s diabetes and how to manage it. The session was attended by approximately five teachers, with the main objective of the session being about providing information to allow the teachers to understand what to look out for.58
The Diabetic Action and Management Plans were updated each year. The most recent one on the school record was signed by Dr Welch on 13 April 2019 and the school nurse, Registered Nurse Heidi Boer on 29 April 2019. At the start of each school year the nurse also holds a medical alert meeting59 for all the teachers presenting information, with a photograph of each child, who have known medical needs/a medical condition, if there is an Action Plan for the student and where to locate it - school Reception and in the health centre. 60 The presentation is also available online through the teachers’ learning management system (LMS). John Charlton (Mr Charlton), Principal at the time, said that the teachers were expected to be across the medical information/review the plans available about any of the students they taught or were going on an excursion or trip with.61 57 TP at page 169.
58 TP at page 33.
59 According to Principal at the time, Mr Charlton, these medical alert sessions occurred twice a year – TP at page 647.
60 TP at page 326.
61 TP at page 647 – 648.
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Other educational enhancement of the teachers’ training and knowledge about diabetes management related to the preparation for school camps. Lachlan attended camps run by both Diabetes Victoria and the school and they were quite distinct according to Ms McMahon. The camps run by Diabetes Victoria were extremely well structured – all the children at these camps had Type I Diabetes, they did their finger pricks at the same time, and they were a great experience she said.62
In relation to the school camps, Ms McMahon explained that in Lachlan’s earlier years at the school, they would meet with the camp organiser, be aware of the intended activities and be quite prescriptive in their instructions about when Lachlan’s blood sugars were to be tested. As Lachlan got older and he was more experienced in managing his diabetes, they all felt more comfortable about Lachlan going on a camp - there was greater clarity about what was involved including a standard routine about what the menu would be. The school also had Lachlan’s Diabetes Management and Action Plan63 which Ms McMahon and Mr Cook understood was taken on the school camps. In addition, the school’s “buddy system” – a teacher attending the school camp who had had additional diabetes training, increased our level of confidence that they had an understanding over and above, you know, the other teachers that were there.64 One of Lachlan’s buddies at camps, the Year 8 camp leader, Ben Woods (Mr Woods) had been slated to attend the trip to Vietnam. According to Ms McMahon, she believed that Mr Woods had also attended a comprehensive diabetes training course specifically to up-skill for the World Challenge/Kilvington Grammar School trip to Vietnam.65
Ms Lionello stated that World Challenge’s expectation of teachers attending on a trip was that they had basic First Aid qualifications and she would ask them to send through their First Aid Certificate so she could put it on the World Challenge system.66 No advanced qualifications were required.
62 TP at page 34.
63 See Exhibit 4 – Diabetes Action Plan 2019 – pages 490 – 497 CB.
64 TP at page 35.
65 TP at page 35.
66 TP at page 233.
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He had previous experience on an overseas school trip having been on the World Challenge organised school trip to Borneo in 2016, which he said was without incident.68 According to Mr Charlton these trips were essentially Teacher 1’s projects, running them himself while also checking in with the deputy principal who oversaw activities such as camps69 and Mr Charlton was comfortable that the deputy principal was ticking off what was required for the trip.70 According to Mr Charlton, it was Teacher 1’s decision not to involve the school nurse in any pre-trip preparation for the World Challenge expedition.71
Teacher 1 had undertaken a basic first aid course which he recalled included a component on diabetes – it mentioned what hypo and hyper were and some basic symptoms.72
In the planning stages before leaving for Vietnam, Teacher 1 had looked at Lachlan’s Diabetes Action Plan73 but did not take a copy of it with him. He was mostly relying on the paperwork that the parents had completed for World Challenge. When Mr Woods dropped out of attending on the trip approximately three weeks before the departure date, no steps were taken to up-skill Teacher 1 with the same level of knowledge Mr Woods had about diabetes.74
Teacher 2 had taught Lachlan in Years 7 and 8. She was aware that he had Type I Diabetes, received the yearly update from the school nurse and was aware where student Action and Management Plans were located in the school – at the Reception 67 TP at page 640.
68 TP at page 344.
69 TP at page 642.
70 TP at page 656.
71 TP at page 648, 657.
72 TP at page 329.
73 TP at page 329.
74 TP at page 678.
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and on-line.75 She said it was her practice to always read the management plans of any students she was teaching – she was not teaching Lachlan in 2018 or 2019. Teacher 2 did attend a Year 10 camp in 2019 that Lachlan was also at, but he was not in the group of children Teacher 2 was supervising at the camp, so she did not read his Plans at that time either.76 Teacher 2 also had her basic First Aid certificate which she said had a small component on diabetes and that she knew what the terms hyperglycaemia and hypoglycaemia meant.
Teacher 2 responded to a school email that said it was looking for a replacement teacher77 for the World Challenge school trip to Vietnam as an allocated teacher was no longer available. When it was confirmed that Teacher 2 was to attend the Vietnam trip approximately 3 weeks beforehand, she said that she would have read the Management Plans of the children going on the trip as it was her practice78 to do so, but she had no personal recollection of having read Lachlan’s. Like Teacher 1, no steps were taken to up-skill Teacher 2’s knowledge about diabetes when she became Mr Wood’s replacement for the trip.
A few days before the trip departed for Vietnam, at build-up day, Teacher 1 had a conversation with Lachlan about his pump, gaining some “basic knowledge” of how it worked. Lachlan showed him the sensor, the App and the reading and they also discussed that Lachlan had a backup for everything if the automatic pumps and things failed.79
Teacher 1 said it was also reassuring that World Challenge promoted itself as having medical backup 24/7 including being able to get a helicopter to you even if you were in the middle of nowhere80 And he said that it was very clear that: 75 TP at page 590.
76 TP at page 591.
77 TP at page 618.
78 TP at page 626.
79 TP at page 334.
80 TP at page 335.
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..the expedition leader was in charge of the expedition including all medical and things like that and final decisions and the school staff were there for pastoral care and wellbeing of the students.81
Teacher 2 also stated that she was advised by Ms Lionello that her role as a teacher in the adult leadership team on the trip was for the pastoral care and wellbeing of the students.82 Anything medical was under the Expedition Leader’s banner and to Teacher 2’s knowledge, the Expedition Leader Ms Walsh, had a far superior first aid and medical knowledge than herself.83 She also understood that World Challenge had doctors on call.84 Teacher 2 said that she was not aware the World Challenge Leadership Team Responsibilities and Supervision Form stated that the adult leadership team were “collectively” responsible for first aid but she could also not recall having seen the document.85 She also conceded that up until the time she became ill we were collectively working as a team for the students – and this included with Ms Walsh.86 Training and knowledge of diabetes management of the World Challenge staff
Ms McMahon said that the family had firsthand experience of World Challenge run trips as their daughter had previously been on a trip to Borneo. The opportunity of the trip to Vietnam came through Kilvington Grammar School who had enlisted World Challenge, but the organisational arrangements were between themselves and World Challenge.87 The trip preparation, lead-up and information about what backup there would be was exactly the same for Lachlan’s Vietnam trip as it had been for their daughter’s trip to Borneo. The medical support that they believed would be available through a World Challenge arranged trip was the main reason they chose it for Lachlan to travel overseas. Critical to their decision making was their understanding that there 81 TP at page 336, 343.
82 TP at page 597.
83 TP at page 597, 624.
84 TP at page 624.
85 TP at pages 621 – 622.
86 TP at page 628 – 629.
87 TP at page 42.
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was 24/7 access for the on the ground team to a co-ordination centre, of which they knew to be two, who: ..would have Lachlan’s information and they in turn would have direct contact to a doctor who could help with any situation.88
Anna Walsh, Expedition Leader for the Vietnam trip did her first expedition with World Challenge to Thailand in 2018. In 2017 she had undertaken a Potential Leadership course with World Challenge and had also undertaken a 5-day intensive Wilderness First Aid course at Swinburne College which she said was more focussed on physical injuries rather than medical conditions. She could not recall anything being covered on diabetes during this course. 89 The sufficiency of documentation available to trip staff that recorded Lachlan’s conditions and actions to be taken if required
On 29 June 2019, Ms McMahon and Lachlan attended Lachlan’s general medical practitioner, Dr Croatto, to discuss the proposed trip to Vietnam and effectively to obtain a “medical clearance” for his participation. Dr Croatto had not seen Lachlan for approximately seven years but had a familiarity with Lachlan’s diabetes as he had diagnosed his Type I Diabetes90 and he also read a lot of the correspondence sent to his practice from Drs Simms and Welch.91 He was aware that Lachlan’s diabetic control was not ideal and that his HbA1c had been running higher in the two years leading up to this appointment but he was cognisant of other factors, in combination, that might be influencing those higher levels including Lachlan’s rapid growth rate, his hormone levels associated with puberty and his activities. Dr Welch said that it was also harder to be obsessionally focused on your diabetic management as it would be for an older adult person.92 When asked to reflect on Lachlan’s diabetic control by Mrs Hartley, 88 TP at page 36.
89 TP at page 511.
90 TP at page 131.
91 TP at page 97.
92 TP at page 101, 110.
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acting on behalf of Kilvington Grammar School, and in particular, that the general direction of Lachlan’s diabetic control was one of deterioration, Dr Croatto said: When I look back it seemed to be up and down over two years. It didn’t seem to be a one-way trajectory of getting worse and worse, and so…when I looked back it did seem to be fluctuating in that last two years, …in those levels.93
Dr Croatto did not agree with Mrs Hartley’s assessment of the HbA1c figures, that the levels in fact should be characterised as Lachlan being on a path of general deterioration.94 He did however, agree with Mrs Hartley that at times – when the HbA1c gets above 10% - that his diabetic control, that is, his HbA1c only, could be classified as poor.95 Dr Croatto also did not agree with Mrs Hartley that the evidence suggested that Lachlan’s control compliance and general condition was not conducive to an overseas trip that he was about to undertake. He said that he had based his reason to clear Lachlan for the trip on many factors not just his HbA1c levels.96
After a lengthy consultation,97 where many matters including the trip were discussed,98 Dr Croatto completed the requisite World Challenge Medical Questionnaire Information Sheet/Diabetes Questionnaire99 and returned it to Ms McMahon to take with her.100 He said that the main thing he discussed with Lachlan about his diabetes was to do with the risk of food poisoning while he was travelling.101 Dr Croatto reflected during his viva voce evidence that he thought Lachlan had been exceptionally engaged in the consultation and switched on. Dr Croatto said that his overwhelming 93 TP at page 119.
94 TP at page 120.
95 TP at page 121.
96 TP at page 124.
97 TP at page 60, 134 – where Dr Croatto refers to it as a “54-minute consultation”.
98 TP at page 61. There was also a discussion about Lachlan’s desire to get his Learner’s Driving Permit.
99 See Exhibit 3, pages 405 and 406 CB.
100 TP at page 99.
101 TP at page 108.
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sense of Lachlan was that he was a very sensible, mature 16-year-old102 and although there was not a direct conversation about blood glucose levels and whether Lachlan should test at particular times or to test for ketones in the event of illness/vomiting,103 Dr Croatto understood from Ms McMahon that there would be additional supports in place on the trip for Lachlan including that that there was going to be teachers on the trip, other responsible adults on the trip from the travel company and that there was going to be 24-hour medical backup.104
Aware that Lachlan was soon to attend on Dr Welch for a scheduled review, Dr Croatto considered it prudent105 to write to Dr Welch to advise him about his consultation with Lachlan and his mother. Dr Croatto wanted to alert Dr Welch that he would also need to be involved in Lachlan’s pursuit of a driver’s licence permit by completing the VicRoads medical form and also to advise Dr Welch about the impending trip to Vietnam, that he had cleared Lachlan to attend, that there would be a 10-day period in the trip that involved staying in a remote area in Vietnam, and that if Dr Welch had any concerns about any of these matters that he should contact Dr Croatto.106 Dr Croatto handed this letter/referral107 to Ms McMahon to give to Dr Welch at the forthcoming appointment.108
On 28 August 2019, Lachlan attended a scheduled appointment with Dr Welch in the company of Mr Cook. Ms McMahon said it was conveyed to her after that appointment that the proposed trip to Vietnam was discussed and general advice given to Lachlan that while away, he should test his blood glucose levels more often.109 Dr Welch also told Lachlan that he needed to “manage things a bit better on the trip to Vietnam.”110 In 102 TP at page 103.
103 TP at page 114.
104 TP at page 104, 128.
105 TP at page 118.
106 TP at page 107.
107 See Exhibit 8 – Thomas Street Family Medical Clinic letter addressed to Dr John Welch dated 29 June 2019.
108 TP at page 125.
109 TP at page 41.
110 TP at page 63.
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confirming that she was not present at that appointment with Dr Welch, Ms McMahon said that it was also conveyed to her that Dr Welch had told Lachlan that he would need to test for ketones if his bloods were high.111 Discussion about having backup to the pump112 - in the event that it failed for some reason and the insulin needed to administered manually, Ms McMahon agreed that this too had been discussed at this meeting and that was why Dr Welch had given Lachlan a prescription for both Lantus, the long acting insulin and NovoRapid, the short acting insulin, and these two insulins and needles formed a part of the packs that Lachlan took with him on the trip.113
Dr Welch agreed with Ms Ryan, acting for World Challenge, that he did discuss with Lachlan in general terms about the need for ketone testing but he did not discuss with him the risk to him in terms of his diabetes if he was to become ill in Vietnam.114 Dr Welch also admitted that he was not aware if Lachlan knew of the significance of the ketone levels that would invoke self-management and the seeking of medical assistance if no improvement and he was not aware if Lachlan had in fact tested himself for ketones previously.115 Dr Welch later clarified that he did talk to Lachlan about doing ketone testing when he was – if he was running high and it wasn’t improving or if he became unwell but did not give him specific numbers.116
Dr Welch also said that he had mistakenly/falsely assumed that Lachlan had attended a diabetic educator to discuss particulars of the trip to Vietnam.117
Dr Welch had no recollection of receiving the letter from Dr Croatto.118 Similarly, he did not sight the World Challenge Medical Questionnaire Information Sheet completed by Dr Croatto or any other World Challenge documents.119 111 TP at page 64.
112 TP at page 46.
113 TP at page 66.
114 TP at page 188.
115 TP at page 189.
116 TP at page 190.
117 TP at pages 182 – 183, 186.
118 TP at page 157, 172.
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Dr Welch said that despite not having seen Dr Croatto’s letter/referral to him he would have not changed the clearance for Lachlan to go on the trip and he would not have contacted Dr Croatto.120
Mr Cook completed the World Challenge Medical Management Form - Diabetes121 and these documents were returned to World Challenge. All the payments, communication, and the forms were uploaded to World Challenge’s portal. On reflection, Ms McMahon conceded that they had not double checked the information they gave to World Challenge against the information held by the school. She said maybe we should have but they did not, they just completed the requested forms.122
Following the presentation to interested students and their parents on 3 May 2019, Ms Lionello followed up any outstanding paperwork, vaccination and visa records and any outstanding payments and would provide these to World Challenge’s Customer Support Centre who would in turn distribute them to the Expedition Leader and the Operations Centre. Ms Lionello said that she did not look at them or read them123 but if a child had identified as having a medical condition, Ms Lionello said that she would have a conversation with the teachers to see if they were okay about taking that student on the trip.124 She said that most schools she dealt with would generally have faith in the teachers going on the trip to have all the medical information that they would need and that there would be a meeting with the out-of-hours contact person prior to the trip so that they understood their role including that they were to have their phone on 24/7. Ms Alex Giamoukoglou (Ms Giamoukoglou) was that person for the World Challenge/Kilvington Grammar School trip. Ms Lionello said she would have had that meeting with Ms Giamoukoglou but she could not remember the specifics, nor whether Ms Giamoukoglou wanted to give her any additional information. Ms Lionello said that she would have told Ms Giamoukoglou that if the school leaders had all the information 119 TP at page 168.
120 TP at page 172.
121 Exhibit 3 - CB at page 407.
122 TP at page 46.
123 TP at page 228.
124 TP at page 229.
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and World Challenge had the documents signed by the doctor and the medical plan, then that was generally enough.125
According to Teacher 1, the school nurse did ask Ms Lionello if she needed to provide anything, like the Action Plans, to World Challenge126 and later in his viva voce evidence Teacher 1 said that he attended the meeting on 23 August 2019, with the school’s after-hours contact person, Ms Giamoukoglou and Ms Lionello, and recalls that Ms Giamoukoglou advised Ms Lionello that she had additional information on the students including Action Plans and these were offered to Ms Lionello but her response was that World Challenge had everything it needed.127
Teacher 1 did not take any additional documentation about the students on the 2016 trip to Borneo and because there were no incidents on that trip, he did not know he needed to take anything on this trip.128
Lachlan’s Diabetes Action Plan and Diabetes Management Plan129 held at Kilvington Grammar School were not taken on the trip to Vietnam by the teachers. Similarly, Lachlan did not take a copy of the plan with him on the trip but according to Ms McMahon, he understood what was in the plan.130 Dr Welch said that this is a standard plan developed in collaboration with Diabetes Victoria, the Royal Children’s Hospital and Monash Children’s Hospital, and could potentially be utilised by anyone as a very good guide for helping Lachlan.131 Dr Welch agreed with Mr Woods on behalf of the family that it was a document that actually contains basic but fundamental information for those that would be caring for a Type I Diabetic adolescent student.132 Although the plan was not designed for a trip to Vietnam but care at school, relevant to Lachlan’s 125 TP at page 232.
126 TP at page 332.
127 TP at page 337.
128 TP at page 344.
129 Exhibit 4 - CB at page 490 - 497.
130 TP at page 91.
131 TP at page 165.
132 TP at page 170.
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circumstances, the plan provided advice that if unwell or vomiting contact should be made with a parent and/or carer and that the “sensible” thing to do would be to seek medical assistance,133 even when the Action Plan gives clear and unambiguous instructions about what to do in a hyperglycaemic situation and testing for ketones and the action that should be taken.134 Dr Welch reiterated that although the intended purpose of the Diabetes Action Plan was not a school camp, it would have been an adequate plan135 for the trip to Vietnam.
Similarly, no document as extensive as the Diabetes Camp Management Plan136 was taken to Vietnam with Lachlan. This document also refers to the Diabetes Action Plan in situations of hyperglycaemia – when the blood glucose level (BGL) is above 15mmol/L.137
Ms Lionello said the Kilvington Grammar School teachers attending the trip to Vietnam and the Expedition Leader, Ms Walsh, would have received all the completed student forms including the declared medical conditions forms, passport details and emergency contact numbers.138 In their “trip pack” there was also a medical handbook and a leader’s handbook depicting the role and responsibilities of the leaders.139
It was Ms Lionello’s impression that World Challenge had received all the necessary information in the completed forms and no additional information was needed or sought through her to obtain any additional medical information. Ms Lionello had never experienced a World Challenge doctor seeking additional information from what was 133 TP at pages 180 -181.
134 See Exhibit 4.
135 TP at page 210.
136 See CB at page 841, TP at page 206.
137 World Challenge proactively reviewed its forms relevant to diabetes in the lead up to this Inquest and created a “Support Plan for Diabetes” – CB at page 895 – which incorporates much of the information provided/seen in the Diabetes Action Plan and Diabetes Camp Management Plan.
138 TP at page 239.
139 TP at page 240.
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contained in the student’s forms, but for most trips this would have occurred through the customer service people of World Challenge and not herself.140
Mr Peter Fletcher (Mr Fletcher), Managing Director of World Challenge said that although World Challenge check that the forms are complete, they do not second guess what’s written.141 He said it is not routine that a UK doctor142 would be involved in the process of checking the forms completed by the families and clearing medical practitioner. He said: Only if there is a real question whether or not the student should travel and we would in that situation either consult with the school, the family, the treating doctor or our own medical advisor.143
Mr Fletcher said that if every section of the form is completed then World Challenge would say they have the medical clearance for the student to go on the trip. Unless it is identified on the form that the student may require support in a particular scenario “input” is not required by World Challenge. Healix do not require the information for support purposes but will have access to a summary of pre-existing medical conditions prepared by the Customer Support Team if a medical incident is opened. The forms otherwise are inputted into World Challenge’s EMS system and the Expedition Leader and school leaders also get a copy of the forms.144
World Challenge’s medical handbook and leadership handbook are provided to the school and to the Expedition Leader but neither handbook had any information on the management of, or recognising of, the same medical conditions that World Challenge required medical clearance for children with any of the conditions of anaphylaxis, asthma, epilepsy or diabetes, to participate in their trips.145 140 TP at pages 255 – 256.
141 TP at page 699.
142 World Challenge Expeditions is based in the United Kingdom.
143 TP at page 699.
144 TP at page 702.
145 TP at page 710.
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Mr Charlton, reflecting on the devasting outcome of Lachlan’s death, said that the school forms were very clear on the symptoms, that the action plan was pretty clear and would have been helpful – that the forms should have gone on the trip.146
Mr Fletcher also agree that Lachlan’s school forms would have potentially been of great assistance to the adult leadership team,147 particularly in regard to the management plan.148 The understanding of Lachlan’s specific condition and needs if he became unwell while travelling
There had been no opportunity to speak to World Challenge Expedition Leader, Ms Walsh until the Kilvington Grammar School students arrived at the airport to depart for Vietnam. Ms McMahon had a conversation with Ms Walsh which lasted approximately two minutes in which she reiterated “that whilst Lachlan can manage his diabetes, he may need some assistance if he is tired or ill.”149 Ms McMahon did not expand on what the assistance might be or what her expectations of the assistance might be and Ms Walsh did not ask her any questions about this or about Lachlan’s diabetes per se other than words to the effect to ask Ms McMahon is he okay with his diabetes.
Similarly, there was no conversation at the airport with teachers Teacher 1, whom Ms McMahon had met before, or Teacher 2 whom she had not met before.
In response to questions from Mrs Hartley about Lachlan’s ability to self-manage his diabetes and in particular about Lachlan’s apparent failure to advise the leadership group of his high blood glucose levels and his apparent failure to test for ketones, Ms McMahon responded: He was a 16-year-old boy who could manage generally very well. In the situation where he was in a foreign country, he didn’t understand the language, he was with people he didn’t know, and he’d started vomiting, I 146 TP at page 659.
147 TP at page 718, 722-723.
148 TP at page 753.
149 Exhibit 2 - Statement of Kirsten McMahon dated 2 March 2022 (CB at 863 – 882), TP at page 48.
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think that could have been an indicator for the leadership on the ground to actually contact the call centre and guide him through ketone testing or medical assistance or whatever was required.150
Dr Welch agreed with Mr Woods for the family that Lachlan or any other adolescent with Type I Diabetes would be reliant to some extent on the adults around them if they were experiencing a severe hypo or hyperglycaemic event. Dr Welch said that in a severe hypoglycaemic event consciousness is affected, so the diabetic is relying on someone else to help them. In a hyperglycaemic event particularly if the diabetic is feeling unwell, their cognition can be affected but if they are in diabetic ketoacidosis their thinking and how they are functioning is affected according to Dr Welch.151
On the Thursday morning when Lachlan advised the adults in the leadership group that he had vomited twice overnight they should have told Lachlan that the plan says that blood glucose and ketone levels need to be checked and that they were going to do it152 but instead, for a period of approximately 9 hours he was “treated” conservatively as if he was someone without a diagnosis of Type I Diabetes and was merely suffering from food related gastroenteritis.
According to Teacher 1, they were influenced in their thinking by the fact Teacher 2 also had symptoms associated with gastroenteritis but by 5.00pm, Teacher 1 articulated that he was concerned and suggested that a doctor be called or the Operations Centre.
Ms Walsh agreed. Teacher 1 did not hear the conversation Ms Walsh had with the Operations Centre and assumed that Lachlan’s diabetes would have been discussed and he also assumed that Ms Walsh was speaking to a doctor.153
151 TP at page 171.
152 TP at page 171.
153 TP at page 355, 372.
154 TP at page 384.
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additional training about diabetes by Kilvington Grammar School even when the teacher who had a higher knowledge of diabetes, Mr Wood, dropped out of attending the trip.
Ms Walsh’s knowledge about diabetes arose from her basic first aid training and this did not cover anything about the emergency management of hypoglycaemia or hyperglycaemia155 and she had no direct experience with students on an expedition who had diabetes or experience through personal relationships.156 Ms Walsh did not know that vomiting or becoming unwell generally, could influence a diabetic’s condition.157 She had never previously heard of the word “ketones”.158
Teacher 2 said that despite her basic First Aid certificate and some understanding of the words hypoglycaemia and hyperglycaemia, she did not know anything about testing blood glucose levels or anything about the term “ketones”.159 Similarly, she had no personal experience of someone who had been unwell through a diabetic condition.
Mr Fletcher said that although the World Challenge adult leader would be responsible for the technical sort of safety of the trip and predominately the teachers are responsible for pastoral care, there were co-responsibilities for the whole adult leadership team and at the top of that list was first aid and medicals.160 The adequacy of communication support for the teachers and expedition leader while in Vietnam
At approximately 6.50 pm on 26 September 2019, Ms Walsh telephoned the Operations Centre via the App “Viber” to get some advice on the management of Lachlan’s illness.
She could not recall the details of the conversation only of giving the call taker Lachlan’s name. Her understanding was that the Operations Centre would have 155 TP at page 512.
156 TP at page 519.
157 TP at page 529, 542.
158 TP at page 539, 554.
159 TP at page 592, 620 160 TP at page 708.
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Lachlan’s medical information including his medication161 to hand. She also understood that the person in the Operations Centre would have had at least the same – if not more – first aid training as her (sic).162 She said that all his signs and stuff were like changing…I wanted a second opinion. I wanted their advice on what to do.163
Stuart Thomas (Mr Thomas) was on duty at the Operations Centre in the UK when Ms Walsh called in for advice on 26 September 2019. According to Mr Thomas, at the beginning of most expeditions the Expedition Leader is meant to obtain two local SIM cards and then provide those numbers to the Operations Centre. There is however, no overall rule about when and how often they should contact the Centre.164 If a student has been identified through the application process as requiring extra support – because they may have a medical condition; the Expedition Leader will be provided with a piece of paper that will inform you of the conditions and any action plan that might be required is meant to be on that piece of paper.165 At the time of this trip, Mr Thomas said that this type of information was directly available to the Expedition Leader but only indirectly available to the Operations Centre through a “different computer system”, called EMS. He could have searched the system and found out the medical information recorded about Lachlan but that would not be a “normal” thing to do according to Mr Thomas. A vomiting case within the first 24 hours of onset was not considered an incident until 24 hours have passed by166 because diarrhoea/vomiting/gastroenteritis is such a common experience for students on similar trips to overseas countries.
Mr Fletcher also confirmed that there was no “flag” system in place on EMS at the time that is, typing Lachlan’s name into the system did not flag that he had a medical condition.
161 TP at page 533 – 534.
162 TP at page 551.
163 TP at page 580.
164 TP at page 287.
165 TP at page 288.
166 TP at pages 294, 309.
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Mr Thomas said that he could not remember all the details of the call that Ms Walsh made to the Operations Centre about Lachlan, but he recalled that he usually used the acronym ‘SAMPLE’ to prompt his questions to the caller, in this case, Ms Walsh. “S” stood for ‘signs and symptoms”, “A” for ‘allergies and age”, “M” for ‘medication’, “P” for ‘past history’, “L” for ‘last oral intake/last time they peed’, and “E” for ‘events leading up to the incident’.167 The notes Mr Thomas took of this call with Ms Walsh reminded Mr Thomas that he had asked about medication (“M”) as he had a note about paracetamol having been given and had a note of the “last time peed” (“L”). He could not recall if he had utilised the remainder of the acronym prompt but having a note about “M” meant he should have been informed about Lachlan’s insulin and he was definite in his response that he was not, as this would have been an immediate red flag to him and a very different conversation168 with Ms Walsh. He said that if he had been aware of Lachlan’s history of diabetes, he would not have treated it as a “vomiting matter” but would have escalated it to Healix straight away.169
Ms Walsh believed that Mr Thomas confirmed with her that her monitoring of Lachlan’s liquid intake was the correct thing to be doing. She also believed that she had been given permission by Mr Thomas to administer the anti-emetic medication Ondansetron to Lachlan if he vomited again.170 Mr Thomas’ evidence was to the contrary in this regard, that he told Ms Walsh that permission would be required to administer Ondansetron, that he would need to register this with Healix and that she would need to call back if she thought the medication was required.171
Mr Fletcher agreed that the conversation between Mr Thomas and Ms Walsh represented a significant break down in potentially providing assistance to Lachlan. He said that the information about Lachlan’s medical history should have come from the caller to the Operations Centre, Ms Walsh but he also conceded that Mr Thomas’ 167 TP at pages 289 – 290.
168 TP at pages 291, 308.
169 TP at page 291.
170 Exhibit 16 at paragraph 43, TP at page 535, 548, 550.
171 Exhibit 11 at paragraph 12.
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failure to ask Ms Walsh about Lachlan’s medical history represented a lack of communication.172
At approximately 7.30pm Ms Walsh contacted the Operations Centre via a message to check if anything she was doing in her management of Lachlan would impact Lachlan’s diabetes.
Mr Thomas could not explain why the message sent through by Ms Walsh after their telephone conversation was not seen by him in the Operations Centre until some 4 hours after Ms Walsh sent it. He believed that it could not have come in and although he explained, in general terms, that an Expedition Leader may send a message by Viber or email – 2 of the communication tools available to them – the Operations Centre/room are triaging tasks and may not place the same importance on the query/request that the Expedition Leader has; but he qualified, that did not happen in this case. When he saw the message from Ms Walsh with the query about Lachlan’s diabetes Mr Thomas said he immediately tried to get hold of her; his concern was very high.173 Mr Thomas tried all the means of communication available to him to get back in touch with Ms Walsh – via her in-country mobile phone and another of the incountry mobile phone numbers he had,174 Viber and also put in a call via the inReach device which he explained is a communication means that is there as your emergency backup.175 Mr Thomas said that he did not have details of the hotel the Kilvington Grammar School group were staying at to call there176 and he could not do anything further until he had heard back from Ms Walsh.
Ms Walsh could not recall what follow up, if any, she did after sending the message at approximately 7.30pm.177 But she conceded that she may not have felt the need to call 172 TP at page 712.
173 TP at pages 297, 298 174 TP at pages 312, 318.
175 TP at page 299.
176 TP at pages 316 – 317.
177 TP at page 537.
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the Operations Centre back by the time she went to bed at approximately 11.00pm as, at that time, it appeared that Lachlan might have been improving.178
Teacher 1 was not aware if his Vietnam SIM card number had been provided to the Operations Centre179 but he was adamant that he did not receive or miss a call from the Operations Centre during the night of 26 September into the morning of the 27 September 2019. Teacher 2’s evidence was of a similar vein180 - she said that her phone was always on and never on silent.181 Concurrent Evidence – Expert Panel: Dr Mark Overton, Professor Geoffrey Ambler & Professor Timothy Jones
The questions posed to the Panel are repeated here for the ease of the reader. Their opinion responses are summarised and referenced noting that Professor Ambler informed me that they had reached consensus on all the questions: Topic 1182, Question A: Do you consider that the material provided or the first aid qualifications of staff on the expedition would adequately prepare a responsible person to make decisions about the welfare and basic medical care of a person with Type I Diabetes who became unwell?
Response: No, there was not sufficient information provided. Specific information was needed on how to respond to ketosis – to respond with extra insulin doses through the use of the pen. World Challenge did not have specific knowledge either on the ground or within their call centre and did not have an escalation process for obtaining expert diabetes advice nor did the Operations Centre have on record that Lachlan had diabetes. Also, basic First Aid training does not include the specific knowledge required for this level of diabetes management on a trip.183 178 TP at page 538.
179 TP at page 377.
180 TP at page 614.
181 TP at 624 – 625.
182 See “Scope of the Inquest” – Issue No. i - The training and knowledge of diabetes management of Kilvington Grammar School and World Challenge staff on the school trip.
183 TP at pages 428 – 429.
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Topic 2184, Question A: What additional information, if any should have been provided to Lachlan and the expedition team on the Vietnam trip, teachers and World Challenge trip leader, regarding the risks and treatment associated with diarrhoea and vomiting, hypoglycaemia and hyperglycaemia?
Response: Although teachers and expedition staff are not expected to be experts in Type I Diabetes they should have been educated about the serious nature of the disease and the potential risks for health to people living with Type I Diabetes, to be able to recognise the signs of conditions that need immediate attention, have a plan and the resources to deliver first aid and they should have known when to seek expert help and the facilities to do so. Their education should include specifics of hypo and hyperglycaemia – to have awareness of the potential causes and risks, what to do when it happens and how to follow up and when to escalate.185 Topic 2, Question B: Who would have been best to provide the information and at what stage of the planning for the trip?
Response: Experts in diabetes should have provided this information, very early on before the trip. A diabetes educator is usually the ideal person; a meeting should have occurred in advance of the trip with Lachlan, his parents and at least one member of the adult leadership team. Such a meeting could have also addressed Lachlan’s current treatment and care.186 Topic 3187, Question A: The World Challenge medical questionnaire information sheet, diabetes questionnaire and medical management form are used for the collection of information for the purpose of vetting students wishing to travel on the expedition. In your view would they: 1. Provide sufficient appropriate information to undertake that vetting process for a student with Type I Diabetes; and 2. Provide 184 See “Scope of the Inquest” – Issue No. ii - The understanding of Lachlan’s specific condition and needs if he became unwell while travelling.
185 TP at pages 429 – 430.
186 TP at page 430.
187 See “Scope of the Inquest” – Issue iii - The sufficiency of documentation available to trip staff that recorded Lachlan’s conditions and actions to be taken if required.
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advice for staff and their management of any aspect of Type I Diabetes in the event of hypoglycaemia, hyperglycaemia or illness in a person with that condition?
Response: To 1. – a qualified yes, it provided reasonable background information but could have included additional questions such as had there been recent education about the management of sick days. To 2. – No, the medical management form did not provide advice for staff that was adequate. The only mention of management was about hypoglycaemia, no mention of hyperglycaemia – how to manage high blood sugars.
Topic 3, Question B: Does Lachlan’s school Diabetes Action Plan 2019, provide appropriate advice for staff with regard to the steps be taken in the event of hyperglycaemia or illness in a person with Type I Diabetes?
Response: This was the best plan available at the time – it gave information about low blood sugars, high blood sugars and mentioned testing ketones. It could however also have had more specific information such as using pen insulin instead of the pump when blood glucose was high and advice on dosing – how much extra insulin to give if the blood glucose is high.188 Topic 3, Question C: Does the World Challenge amended support plan for diabetes189 provide appropriate advice for staff with regard to the steps to be taken in the event of hyperglycaemia or illness in a person with Type I Diabetes?
Response: There were some omissions related to the self administration of Glucagon in hypoglycaemia, the blood levels used for the definitions of hyperglycaemia and hypoglycaemia were too high and too low respectively and there was not enough detail for management.190 188 TP at pages 431 – 432.
189 See CB at page 671.
190 TP at page 432.
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Topic 3, Question D: Does the most recent amended World Challenge support plan for diabetes191 provide appropriate advice for staff with regard to the steps to be taken in the event of hyperglycaemia or illness in a person with Type I Diabetes.
Response: It is improved on the previous plan by taking on the suggestions of the inadequacies it contained but there are parts that are too vague for example where the plan refers to increasing insulin in hyperglycaemia events – the advice should be more specific such as to give insulin via a pen and not the pump and should provide advice on how the increased dose of insulin should be calculated192 Topic 3, Question E: Do any of the above documents adequately convey the importance of ketone testing in a person with diabetes who has become unwell and the potential seriousness of diabetic ketoacidosis?
Response: Yes, the school Diabetes Action Plan and the most recent World Challenge plan are the best of the bunch but although they both mentioned ketone testing they could be improved upon by providing more detail about what to do for management.193 Topic 4194, Question A: What resources or advice should be available to expedition staff responsible for a young person with Type I Diabetes whilst in a remote or developing country setting. Was this provided?
Response: Education should have been provided to Lachlan, his family, to a teacher and to a member of the expedition staff that would be on the trip by a diabetes educator. In addition, specific resources should have been carried which detailed action plans for sick days, hypoglycaemia, ketosis and other possible acute events that may occur with diabetes. The World Challenge Operations Centre should have 191 See CB at page 895.
192 . TP at page 433.
193 TP at page 433.
194 See “Scope of the Inquest” – Issue No. iv - The adequacy of communication support for the teachers and expedition leader while in Vietnam.
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had a record that Lachlan had diabetes, but they did not when the call came through to them and this prejudiced the advice that was given – or not given.195 Topic 4, Question B: The World Challenge Operations Centre was utilised by expedition staff to seek advice after Lachlan became ill. What level of training and knowledge should call-takers have to adequately triage medical emergencies and a presentation such as Lachlan’s?
Response: The Centre should have had a record that Lachlan had diabetes. The call takers do not need to be medically, or nursing trained, and the level of training can be basic as long as the call takers have a very clear process and mechanism to escalate. They should be supported by a system that flags when escalation is required. For example, if a call is received that a participant known to have diabetes is sick there should be an immediate escalation to a diabetes expert.196 Topic 4, Question C: What information should be available to World Challenge Operations Centre call takers regarding students on the trip and their medical conditions to enable appropriate advice to expedition leaders?
Response: Medical information on file about individual students and their medical conditions and the means for rapid escalation for expert diabetes input.197 Topic 5,198 Question A: What are the features of diabetic ketoacidosis, and can these be distinguished from other illnesses?
Response: Vomiting, feeling unwell, abdominal pain, dizziness, rapid breathing, confusion and eventually coma and it can be distinguished from other illnesses with tests.199 195 TP at page 434.
196 TP at page 435.
197 TP at page 435.
198 See “Scope of the Inquest” – Issue No. v - The time frame between Lachlan first reporting being unwell, that is, vomiting at 8.00am on 26 September 2019 and his eventual transfer to hospital approximately 24 hours later, hence, should local medical attention have been sought sooner.
199 TP at page 436.
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Later the Panel agreed that increased thirst, irritability and tiredness could also be features of Diabetic Ketoacidosis (DKA).200 Topic 5, Question B: What features of DKA were present in Lachlan?
Response: Lachlan was unwell; he had abdominal pain and he was vomiting. They are the clinical features.201 Topic 5, Question C: In the setting of an illness such as experienced by Lachlan, are absolute blood glucose levels, for example, a certain numerical value of millimoles per litre, a reliable indicator of the presence or potential for DKA.
Response: On their own, blood glucose levels do not demonstrate DKA. Usually in DKA there is a high blood glucose level and it is recommended to people with diabetes that they check for ketones if their blood glucose level is 15 to determine if they are at risk of, or in DKA.202 Topic 5, Question D: The range of HbA1c levels for Lachlan listed on pages 52 and 53 of the Coronial Brief in the statement of Dr John Welch have been discussed and put to witnesses for comment during evidence. In your assessment, are the change in levels over the period of time listed indicative of a diabetic with declining health generally, or typical for an adolescent of Lachlan’s age?
Response: These levels are indicative of declining health – they are not typical of someone of Lachlan’s age. They are higher than average with the average haemoglobin at this age will be in the 8s.203 Topic 5, Question E: What is the importance of measuring ketones and how should the result direct the actions of the affected person or responsible staff?
Response: Measuring ketones is critical where someone is unwell, vomiting or has a high glucose level – the results will be determinant to what to do next.204 200 TP at page 444.
201 TP at page 436.
202 TP at page 437.
203 TP at page 437.
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Topic 5, Question F: At what point in an illness should an individual with Type I Diabetes or supervising staff become concerned that medical attention is required?
Response: In this case, the point in the illness where they should have been concerned was Lachlan’s vomiting.205 Topic 5, Question G: What are the key considerations in the assessment, care and medical decision-making with a person with Type I Diabetes who becomes unwell?
Response: The first step in management is consideration of the individual’s background – whether they had any previous episodes of DKAs, how optimally their diabetes is managed, current symptoms – any vomiting, abdominal pain, thirst, rapid breathing, rapid pulse, and then to do blood tests for glucose and ketones and possibly pH. With all of this information then a treatment plan can be put together with consideration whether they need fluids/intravenous fluids, they will need more insulin and they will need close monitoring and follow-up206.
Topic 6207, Question A: Lachlan, by all accounts, was a well-informed adolescent with Type I Diabetes, who had not experienced DKA previously. Is it likely he would have an appreciation of or be aware of the implications for his diabetes, from a vomiting illness associated with hyperglycaemia?
Response: The basic assumption by World Challenge is that the person with the medical condition will manage their own condition while the assumption of the family, school and Lachlan’s doctors is that whilst travelling overseas, World Challenge will have the resources to help if there is a medical problem – so the answer to the question is no, because Lachlan had no experience managing DKA and minimal experience managing sick days as he had been quite well with his 204 TP at page 437.
205 TP at page 437.
206 TP at page 438.
207 See “Scope of the Inquest” – Issue vi - The apparent reliance on Lachlan to adequately self-manage his diabetes in the circumstances of being unwell and guide staff in his care.
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experience of diabetes. Further, if he had had any recent experience of managing sick days and ketone testing, he had not taken that education on board.208 Topic 6, Question B: What are the potential effects of hyperglycaemia and DKA on cognitive function, and how might this have affected Lachlan’s ability to manage his condition, respond to staff and to guide them in his care?
Response: As DKA progresses, it has increasing effects on cognitive function eventually resulting in coma. Throughout the day of Lachlan’s initial presentation of vomiting and getting to the hotel in Hue, his ability to think rationally, selfmanage and guide adults to help him would have been diminishing.209 Topic 6, Question C: At what point in Lachlan’s evolving illness do you consider that medical attention should have been sought?
Response: There were several missed opportunities to seek medical attention. The first was at 8.00 am when he first vomited – for a diabetic that event should have set off alarm bells and the Operations Centre should have been contacted then. The next missed opportunity to seek medical attention was when the arrived at the hotel in Hue at about 2.00 pm that afternoon and Lachlan was still unwell.210 Later the Panel clarified that 8.00 am was the time that Lachlan reported to the adult leadership team that he had vomited overnight so that was the time/their first opportunity that they should have sought medical attention on his behalf. Ideally it would have been when Lachlan first vomited.211 Topic 7212, Question A: Based on the information available, how well controlled was Lachlan’s diabetes prior to travel?
208 TP at page 439.
209 TP at page 439.
210 TP at page 440.
211 TP at page 445.
212 See “Scope of the Inquest” – Issue vii - The soundness of the decision to clear Lachlan to travel on this school trip given his diabetes and management and history of the same.
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Response: Lachlan’s diabetes control was suboptimal and deteriorating prior to travel. His level of control was in the approximate bottom 10 percent for adolescents of his age, and this suggested inadequate knowledge and/or suboptimal self-management behaviours.213 Later the Panel agreed that it was difficult to manage diabetes especially in adolescents, but the difficulties are not just experienced by adolescents. In managing diabetes, you are trained to match insulin with activities and food – it is not just about the psychology of the person it is about physiology also and the physiology of adolescents makes it more difficult to control because they are growing and have fluctuating hormones.214 Topic 7, Question B: Does diabetic control, as measured by HbA1c, in a young person who has not experienced significant diabetes related illness translate to the risk of developing serious diabetes related illness whilst travelling? If so, how?
Response: This translates to increased risk at anytime and when travelling those risks are further escalated. When glucose levels are running generally high much less needs to happen for you to tip over into ketosis or ketoacidosis.215 Topic 7, Question C: Does the overall long-term quality of diabetes control influence the likelihood of development of DKA in the setting of intercurrent illness?
Response: Yes, it does – if you have high HbA1c that means your average blood glucose level is very high and it is much easier to tip over into DKA in an intercurrent illness.216 Later the Panel agreed that the fact that Lachlan had not had an admission to hospital with DKA between the age of 9 years when he was diagnosed with 213 TP at page 440.
214 TP at page 448.
215 TP at page 441.
216 TP at page 441.
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diabetes and the age of 16 years indicated that he was managing his diabetes217 well enough but based on his average blood glucose levels, he was not managing it well.218 Topic 7, Question D: If so, was Lachlan’s overall control in a range that put him at increased risk whilst overseas?
Response: Yes – recent data we looked at indicates that young people in this situation would have about a 10-fold increase in the risk of DKA in any given period at this level of control compared to someone who was regarded as having optimal control.219 Later the Panel was asked to confirm that that there was agreement that most medical practitioners would have cleared220 Lachlan for the Vietnam trip as Professor Jones had stated in his expert opinion report. Dr Overton said that he agreed with Professor Jones. Professor Ambler reiterated his opinion as expressed in his expert opinion report that he would not have cleared Lachlan without putting in place other measures and other things to ensure optimal control because Lachlan’s self-management was demonstrably very sub-optimal. He did however concede that from a general practice point of view, it was appropriate to clear Lachlan on general medical grounds.221
Professor Jones referred me to the suggestions he had made in his expert report222 and to which Professor Ambler said he endorsed, and Dr Overton said he had nothing further to add to those suggestions.
217 TP at page 455.
218 TP at page 457.
219 TP at pages 441 - 442.
220 See page CB at page 862 – Professor Jones says: “In my experience, some physicians would not have given clearance but most would have, provided a specific plan had been put in place to address the risk.” 221 TP at page 463.
222 CB at page 862, Exhibit 15.
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Diabetic Education in schools since Lachlan’s passing
Dr Welch is involved in the development of educational material around diet and diabetes and insulin pump therapy for school camps. He informed me that there is nationwide pilot program underway where all the major diabetes centres in Australia have a Diabetes Nurse Educator employed with the role to liaise with schools and to provide education to them and that this is being expanded to school camps and development of individualised plans for attending camps.223 Restorative and preventative measures implemented by World Challenge
World Challenge have responded to the circumstances of Lachlan’s death by implementing changes that they have identified may have contributed to the response to Lachlan’s decline in health. The ability of the Operations Centre to contact the place of accommodation of a trip has been improved by World Challenge now making all bookings for accommodation and transport rather than the students. The inability of Mr Thomas to contact the accommodation place of Lachlan’s trip in Hue when he became aware of Ms Walsh’s message should no longer be a communication impediment.
World Challenge has also developed a Standard Operating Procedure (SOP) for the Operations Centre to follow should a call be received about the wellness of a student with diabetes. No such SOP was in existence at the time, but it is moot whether it would have made a difference given that it is the evidence of Mr Thomas that he was neither told by Ms Walsh that Lachlan had diabetes and he did not have Lachlan’s medical information readily available to him to check.
World Challenge has also reviewed all its’ medical forms of which Mr Fletcher advised there are 6 in total. The new forms were created in the weeks preceding 17 March224 2022, when the Inquest commenced. Medical practitioners, consultants and Healix have been involved in the review and the latest version of the Form, received in the weeks preceding the Inquest occurred following receipt of Professor Jones’ opinion which specifically commented on World Challenge’s previous newly created form.225 Of 223 TP at page 178 – 179, 182. See Diabetes Camp Management Plan form at CB at page 841.
224 TP at page 739.
225 TP at page 754 – 755.
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relevance, is the Support Plan for Diabetes226 form which provides a space for information about hypoglycaemia and hyperglycaemia. The newly devised form also has details around measuring ketones and information about ketoacidosis which Mr Fletcher conceded was not contained in the original form – the form completed by Lachlan’s doctor and family.227 The new forms are accompanied by an Information Sheet for the parents to provide some understanding what the forms are for and to set a bit of context for the trip.228
Notification to WorkSafe
On 15 June 2022, the Court through Counsel Assisting, LSC Lord, was notified by email communication from the organisation, Type I Voice that they had made a notification to WorkSafe Victoria (WorkSafe) about the circumstances surrounding the death of Lachlan Cook and that an Inquest was occurring.
On 14 July 2022, Type I Voice provided the Court through Counsel Assisting a response they had received from WorkSafe stating that: “Your letter was referred to WorkSafe’s Enforcement Legal team, who have commenced an investigation under section 131 of the Occupational Health and Safety Act 2004.”
Despite numerous enquiries with WorkSafe by the Court since that time, no indication has been provided as to the state of their investigation and whether prosecution proceedings are anticipated.
226 CB at page 895.
227 TP at page 718.
228 TP at page 731.
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COMMENTS Pursuant to section 67(3) of the Coroners Act 2008, I make the following comments connected with the death:
During the course of giving evidence as a member of the Expert Panel, Professor Jones responded to a question from Mr McLay of Counsel, that he was not suggesting that an adolescent with less than the aspirational level of 7 per cent HbA1C should not be allowed to go on a camp. Professor Jones said that diabetes is difficult and mental health problems are common in adolescents with Type I Diabetes and not allowing them to do the youthful activities that their friends are doing would not be helpful to them. He said that through planning and having mitigation strategies in place to prevent serious consequences, endocrinologists do their best not to block them from participating.229 Professor Jones said that some of these mitigation factors included meeting with the family, the child, the team they are travelling with, increase their education about their condition – to try to put things into place to stop this event from happening.230 Unfortunately, there was no collaborative approach to Lachlan’s diabetes – to the putting in place of the mitigation factors that might have prevented his untimely death.
Complacency and assumptions on the part of Lachlan’s family, his school, their teachers and World Challenge have, in varying degrees contributed to the events like a snowball gaining speed and size as it rolls down a hill. Lachlan was a teenager and although he was diagnosed with diabetes at age 9 years he had been managing it successfully enough such that he had never had a serious illness and in particular had never experienced DKA. His parents had confidence in their son’s ability to manage his diabetes, knew he was well kitted with his equipment including alternatives to manage changing circumstances, they trusted the school and their teachers as they had been able to do over the years that Lachlan had been at Kilvington Grammar School, they trusted World Challenge to look out for their son because their daughter had been on a trip with the organisation without incident and significantly they were told of the expertise 229 TP at page 458.
230 TP at page 458.
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of World Challenge staff and the 24/7 medical support provided to their tours. The teachers of Kilvington Grammar School made assumptions about the level of medical knowledge of the Expedition Leader and the access to medical support and indeed their own roles without doing very much to inform themselves of their actual responsibilities and what exactly they should be aware of in relation to Lachlan’s condition – Teacher 1 was somewhat complacent about these matters as he too had had a previous experience with World Challenge without incident. Teacher 2 did little if anything to inform herself of her responsibilities or of Lachlan’s condition on the assumptions that everything was in hand, and she had only a few weeks to get organised herself having joined the trip only a few weeks before its departure date. Kilvington Grammar School was complacent about the involvement of their students and their teachers going on the World Challenge trip, perhaps in part due to the previous engagement with World Challenge leading to assumptions that all would be well. Lachlan’s medical practitioners were also complacent and made assumptions of their own – Dr Croatto believed that Lachlan was and had been well with his diabetes and thus managing it maturely and he assumed that Dr Welch would doublecheck that his clearance of Lachlan was appropriate. Dr Welch assumed that Lachlan would and could manage variations in his blood glucose level and assumed, based on little, that the Diabetes Nurse Educator would have a discussion with Lachlan and the family before he went on the trip. Both doctors had been told of the 24/7 medical support that World Challenge purported to provide. World Challenge made assumptions that Lachlan could manage his own diabetes regardless of the circumstances or his state of wellness. This was based on very little – they did not look at the medical forms completed on behalf of Lachlan and the level of expertise of their Expedition Leader and the support that was allegedly available for her and the young people in her charge, fell well short of everybody else’s assumptions about the calibre of the organisation.
I acknowledge that Dr Welch indicated to the Court that he now ensures a referral to a Diabetes Nurse Educator for students going on camps and ensures the development of a camp-specific plan.
Throughout the Inquest, Kilvington Grammar School portrayed that it was Lachlan and others involved with Lachlan, whether family or medical practitioners, that did not act _______________________________________________________________________ 55 of 64
responsibly by allowing Lachlan to participate in the World Challenge/Kilvington Grammar School trip to Vietnam. Kilvington Grammar School were slow to make any concessions about their involvement in the decision making, preparation or indeed lack of involvement in the decisions necessarily related to how the trip would be conducted.
Indeed, any concessions I interpreted has having been made particularly through Mr Charlton, dissipated during their closing submissions. I do not accept Mrs Hartley’s submission that the school was led into a state of ignorance about many of the risks it was facing in relation to Lachlan and that ignorance which derived from a range of information not being available to it from the treating team and from World Challenge and others resulted in the school proceeding on the basis that Lachlan had been cleared to go on the trip and that the consequences of his diabetes would be adequately managed by World Challenge.231
This does not align with their reliance on a defence that they were led to believe Lachlan could always self-manage his diabetes; this reflects a school prepared to be able to deal with Lachlan’s illness in different circumstances/environments such as school camps.
232 See Teacher 1’s evidence in this regard – TP at pages 366 – 367 and Teacher 2’s evidence – TP at page 612, 616.
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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.
And similarly, there is no evidence that Kilvington Grammar School took any steps to satisfy itself that the purported assurances of expertise and support systems of World 233 TP at page 386.
234 TP at page 390.
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Challenge were sufficiently nuanced to be able to deal with the medical conditions of their students. They allowed eight of their students and two of their teachers to go on an overseas trip with less information about the student’s medical conditions, and into a more complicated process to receive medical attention if needed, than they would have tolerated/allowed on one of their own school camps or with an OEG (The Outdoor Education Group) camp.
Kilvington Grammar School and World Challenge did not hold a pre-trip briefing specific to students with pre-existing conditions, including Lachlan which represents an opportunity lost for the sharing of information about these children and to ensure that risk minimisation strategies were in place before the trip commenced.
I do, however, acknowledge that Kilvington Grammar School has reflected on the tragedy of Lachlan’s death and Mr Charlton did concede that the school’s own medical documentation should have gone on the trip as they would have been helpful. He also gave a qualified concession when he said it was a big call not to involve the school nurse but that it was a reasonable call at the time.235 Restorative and preventative measures have been implemented at Kilvington Grammar School which I also acknowledge. Relevant to Lachlan’s death it is now mandated in the Overseas Trip Policy and procedures that the school nurse is consulted about students with known medical conditions. Teachers are also required to do diabetes training which is in addition to what is covered in the basic First Aid Course. There have also been amendments to the Camps and Outdoor Education Policy and Overseas Trip Policy and procedures improving communication and preparation between third party providers, the school and parents. Kilvington Grammar School now also ensures with parents that the student can undertake the steps outlined in the action plan and the diabetes management plan and these plans are available to staff remotely via their mobile phone or iPad. Contracts between third party providers and the school have been revised improving on the expected actions in relation to medical management.
Ms Walsh did not have any expertise in diabetes and in fact had no more training on this medical condition than Kilvington Grammar School’s teachers. World Challenge 235 TP at page 659.
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did not provide Ms Walsh with any additional training in diabetes despite their knowledge of Lachlan’s condition before the trip commenced and took no additional steps to ensure that Ms Walsh could appropriately manage any concerns she might have about managing a child with diabetes including what might constitute an emergency.
This was only Ms Walsh’s second expedition with World Challenge.
I am unable to reconcile the evidence of Mr Thomas about his attempts to call back Ms Walsh through different mediums with the evidence of Teacher 1, Teacher 2 and Ms Walsh that none of them received any messages or notification of missed calls from the Operations Centre.
The respective recollections of Teacher 2 and Ms Walsh were however quite profoundly poor despite the context of their viva voce evidence – however, I do acknowledge the possibility that their respective inability to recall so much related to Lachlan’s death is because of the circumstances of Lachlan’s death. Furthermore, Teacher 2 was by all accounts incapacitated herself by illness during the same period of time that Lachlan’s health was deteriorating which further explains her inability to recall detail during this period of time.
In response to a proposition put to him by Mrs Hartley of Counsel that the adult members of the trip were just lay people who could not be expected to distinguish between vomiting from gastro and getting to first base thinking that they should consult a sick day plan or diabetes action plan, Dr Overton from the Expert Panel responded that they were not just lay people off the street. These were teachers, an expedition leader who were responsible for the care of the children under their watch….they knew about Lachlan’s diabetes condition so it should have come into their mind.236 I concur.
I am unable to reconcile the extent that World Challenge purported to have all the knowledge and backup for any untoward event happening on one of their Expeditions and that there was such a fundamental failure of its system of communication and access to crucial medical knowledge by the Communications Centre.
236 TP at page 481.
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There is a new diabetes SOP, and the Incident Management System now flags student conditions where medical management forms are saved. In addition, there is a prompt to ensure call-takers at the Operations Centre check the medical history of a student they are receiving a call about. Expedition Leaders are now instructed to keep their mobile phones on at all times, including overnight.
The procedures, the teacher training, and the rigorous practices of the school nurse in updating the information on the children, like Lachlan, who have special medical needs and providing the same to the teachers, served the school and Lachlan well. As such, there was no basis for me to delve into or indeed hypothesise about what might have happened if Lachlan had become unwell at Kilvington Grammar School. My investigation and thus the Inquest focused on how did this apparent safe environment let Lachlan down when he left the geographical confines of the school to go on an _______________________________________________________________________ 60 of 64
overseas “school camp” with two of Kilvington Grammar School’s teachers in association with World Challenge Expeditions, who organised the trip to Vietnam.
RECOMMENDATIONS Pursuant to section 72(2) of the Coroners Act 2008, I make the following recommendations connected with the death:
With the aim of promoting public health and safety and preventing like deaths, I recommend that World Challenge Expeditions create and implement a policy directed at improving communication and the sharing of information with the schools they are engaging with.
With the aim of promoting public health and safety and preventing like deaths, I recommend that World Challenge Expeditions through its revised/renewed 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 and/or special needs by holding pre-trip meetings with the trip leaders, attending teachers, parents, a member of the child’s medical treating team or the school nurse, and the student.
With the aim of promoting public health and safety and preventing like deaths, I recommend that World Challenge Expeditions update the Leader’s Manual and pretrip training material to include information about diabetes, hypoglycaemia, hyperglycaemia, ketone testing and safe levels of blood glucose levels.
With the aim of promoting public health and safety and improving the sharing of medical information, I recommend that 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.
FINDINGS Having held an inquest into the death of Lachlan McMahon Cook, I make the following findings pursuant to section 67(1) of the Act: _______________________________________________________________________ 61 of 64
I find that LACHLAN MCMAHON COOK, born 26 May 2003 died on 4 October 2019 at the Royal Children’s Hospital, 50 Flemington Road, Parkville 3052 after falling ill in Vietnam whilst on a school trip, organised by World Challenge Expeditions.
I find that Lachlan McMahon Cook, a 16-year-old adolescent - but still legally a child; was generally capable of managing his diabetes adequately on his own. He had been diagnosed with Type I Diabetes at age 9 years and had no hospital admissions since his diagnosis, he attended quarterly consultations with his endocrinologists and had attended sessions with a diabetic educator when directed to, he knew to reset his pump to local Vietnamese time and while in Vietnam he was managing his pump around activities but I also find that his ability to manage his own condition declined when he became ill, as can also occur with an adult. I find that he should not have been expected to self-manage from 8.00am on 26 September 2019 when it was apparent that he was unwell.
I find that World Challenge and Kilvington Grammar School failed to ensure that their staff had the requisite training and thus skill set to care for the children under their care – in loco Parenti,237 whilst on an overseas school trip. Specifically, World Challenge and Kilvington Grammar School failed to support their staff to have the necessary intelligence about Type I Diabetes that would have supported them to address Lachlan McMahon Cook’s illness in an informed and timely manner. No supervising adult on the Vietnam trip had specific training around diabetes management, the potential impact of intercurrent illness to a person with diabetes, or sufficient familiarity with the symptoms of high blood glucose levels/hyperglycaemia, ketone testing or DKA.
I find that prior to the school trip departing for Vietnam an opportunity was lost to have a co-ordinated meeting between the school, World Challenge, Lachlan McMahon Cook and his parents and treating team where the sharing of information about his condition and the management of the same would have provided the intelligence the supervising adults on the trip so clearly lacked.
237 In loco parentis is a Latin term meaning "in [the] place of a parent" or "instead of a parent." The term refers to a common law doctrine which denotes the legal responsibility of some person or organization to perform some of the functions or responsibilities of a parent.
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AND I further find that Kilvington Grammar School failed to support their own staff who were acting in loci Parenti by ensuring that they had available to take with them on the school trip, either in hard copy or electronically, the detailed contemporaneous Diabetes Action and Diabetes Management Plans for managing Lachlan McMahon Cook’s Type I Diabetes - documents that already existed at Kilvington Grammar School.
AND I find that Kilvington Grammar School failed to provide World Challenge with relevant medical information about one of their students being the detailed contemporaneous Action Plan for managing Lachlan McMahon Cook’s Type I/insulin dependent diabetes that already existed at Kilvington Grammar School.
AND I find that as a consequence of World Challenge failing to ensure their staff member had all relevant documentation in relation to Lachlan McMahon Cook’s openly disclosed medical condition and as a consequence of Kilvington Grammar School failing to ensure that its teachers carried with them relevant documentation in respect of student medical conditions, a significant opportunity was lost to these staff members to have the information that would have enabled them to act in an informed and timely way to the onset of Lachlan McMahon Cook’s illness.
I find that there is clear and cogent evidence that the failures and shortcomings of World Challenge Expeditions and Kilvington Grammar School contributed to the death of Lachlan McMahon Cook.
I accept and adopt the medical cause of death as ascribed by Dr Malcolm Dodd and I find that Lachlan McMahon Cook died from hypoxic/ischaemic encephalopathy in the context of diabetic ketoacidosis in circumstances that I find were easily avoidable and rectifiable before he lapsed into extremis.
AND having considered all the evidence and applying the requisite standard of proof, I find that the death of LACHLAN MCMAHON COOK was preventable, and his death is a tragedy to all who knew and loved him.
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To enable compliance with section 73(1) of the Coroners Act 2008 (Vic), I direct that the Findings will be published on the internet.
I direct that a copy of this Finding be provided to the following: Ms Kirsten McMahon Mr Peter Cook Brave Legal on behalf of Lachlan’s family Mr John Arranga, Ball + Partners on behalf of Dr John Welch Ms Annabelle Mann, General Counsel, Royal Children’s Hospital Mr Peter Harris, Avant Law Pty Ltd on behalf of Dr John Croatto Ms Cecelia Irvine-So, Moores previously on behalf of Kilvington Grammar School Mr Adam Foster, Colin Biggers & Paisley Lawyers on behalf of Kilvington Grammar School G C Legal on behalf of World Challenge Expeditions WorkSafe Victoria Signature:
AUDREY JAMIESON CORONER Date: 20 December 2023 _______________________________________________________________________ 64 of 64
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