Inquiry into death of student Lucas Mazzei at Henley Beach Elementary School shows death was avoidable

The parents of a special needs student who choked on a nectarine stone have criticized the Department of Education, claiming they were “misled” after his death.

Lucas Latouche Mazzei, a five-year-old student at Henley Beach Primary School in South Australia, died in 2017 after choking on a piece of fruit.

The little boy was one of 350 people worldwide with an incredibly rare genetic condition called succinic semialdehyde dehydrogenase deficiency, which causes developmental delays.

On Friday, a report of his death found it was preventable.

SA Deputy Medical Examiner Ian White criticized the school, saying staff did not have adequate first aid training.

His parents, Daniela Mazzei and Miguel Latouche, gave an emotional speech in court on Friday, criticizing the Education Ministry’s handling of their son’s death.

Lucas Mazzei died at Henley Beach Primary School in South Africa in 2017 after choking on a nectarine rock

His parents Daniela Mazzei and Miguel Latouche (pictured leaving Coroner’s Court on Friday) said they felt “misled” and criticized the Department of Education’s handling of their son’s death

“It was clear that the education department did not know or want to know how a young boy in their care died,” his mother told reporters outside of court.

“They weren’t interested in learning from his death to make sure something like this never happens again.”

“The school’s very first communication of his death was disingenuous and our speeches to the then CEO were virtually ignored.”

“We were misled into believing that an investigation was underway.

“Adding to our grief was what can only be described as organizational abuse to protect the department’s reputation.”

The family said they had been looking for answers since the day their son died and described the lack of information that was provided to them as “extremely hurtful, even cruel”.

“We are asking the Department of Education to acknowledge that Lucas died because something went wrong in one of their special classrooms where he was left unsupervised,” the family said.

On the day Lucas died, he was not with his classmates because his teachers feared he might be in danger of choking on objects during science class.

He sat in front of his favorite TV show, The Gruffalo, which he watched on the whiteboard in the classroom.

He was not with his classmates the day Lucas died, as his teachers feared he might risk choking on objects during a science class if he got his hands on a nectarine

There he found a nectarine on which he eventually choked.

At the coronial hearing, it was reported that a supervising teacher had asked another teacher to look after him.

However, Mr White says Lucas was known for putting objects in his mouth and the teacher supervising him had limited vision while looking at the screen.

“Lucas was left unattended for an unacceptable amount of time,” White said in his report.

“This error, involving his extremely dedicated and compassionate teacher and his SSO, was a direct cause or connection to Lucas obtaining the nectarine and attempting to eat it uncut.”

It wasn’t until the five-year-old was asked if he needed to go to the bathroom that the teacher realized his eyes were glazed and knew something was wrong.

In the ensuing moments, the teachers tried in vain to save his life by slapping his back and even lifting him up by his feet so that he was lying on his head, while the staff slapped his back.

A short time later, paramedics began resuscitation and quickly rushed him to the hospital, where he was pronounced dead shortly thereafter.

“Luca’s parents were filled with sorrow at the death of their precious little son that day,” Mr White said.

A week after Lucas’s death, the school letter stated that he had died “following an isolated medical incident related to his condition”, a statement Mr White called “misleading”.

It wasn’t until the five-year-old was asked if he needed to go to the bathroom that the teacher realized his eyes were glazed and knew something was wrong

A plaque was then placed outside the classroom where he suffocated, about which the family was not consulted.

Mr White made several recommendations that emerged from the coronal inquiry including the requirement that all teachers should have current qualifications in the provision of first aid.

It was also recommended that the department review its procedures and policies on the storage and consumption of food and drink at the school.