Inquiry into death of schoolboy Lucas Mazzei at Henley Beach Primary reveals death was preventable

The parents of a special needs schoolboy who choked to death on a nectarine stone have slammed the Department of Education claiming they were ‘misled’ after his death.

Lucas Latouche Mazzei, a five-year-old student at South Australia’s Henley Beach Primary School, died in 2017 when he choked to death on a piece of fruit.

The young boy was one of 350 people worldwide with an incredibly rare genetic condition known as succinic semialdehyde dehydrogenase deficiency which causes developmental delays.

On Friday a report into his death found it was preventable. 

SA Deputy Coroner Ian White criticised the school, saying the staff did not have adequate first-aid training.

Outside court on Friday his parents Daniela Mazzei and Miguel Latouche gave an emotional speech slamming the Department of Education’s handling of their son’s death.

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

‘It was clear the Education department did not know or want to know how a young boy died in their care,’ his mother told reporters outside court.

‘They were not interested in learning from his death to ensure that this never happened again.

‘The very first communication on his death from the school was disingenuous, and our approaches to the then chief executive were effectively ignored.

‘We were left misled and made to believe that there was an ongoing investigation.

‘Adding to our grief was what could only be described as organisational abuse to protect the reputation of the department.’

The family said they have been searching for answers since the day their son died and described the lack of information provided to them as ‘extremely hurtful, even cruel’.

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

On the day Lucas died he was away from his classmates as his teachers were worried he may be at risk of swallowing objects during a science lesson.

He was situated in front of The Gruffalo, his favourite TV show, which he was watching on the classroom whiteboard.

On the day Lucas died he was away from his classmates as his teachers were worried he may be at risk of swallowing objects during a science lesson when he got hold of a nectarine

While there he located a nectarine, that he eventually choked on.

The coronial hearing was told that a supervising teacher had asked another teacher to watch him.

However, Mr White says Lucas was known for putting objects in his mouth and the teacher supervising him had an obstructed view while he watched the screen.

‘Lucas was left unsupervised for an unacceptable period of time,’ White said in his report.

‘This error involving his extremely dedicated and compassionate teacher and SSO was a direct cause or link to Lucas obtaining the nectarine and attempting to eat it uncut.’

It was only when the five-year-old was asked if he needed to go to the bathroom that the teacher saw his eyes were glassy and knew something was wrong.

In the moments that followed, teachers tried in vain to save his life, banging on his back and even lifting him by his feet so he was upside down with staff slapping his back.

A short time later paramedics commenced CPR and rushed him to hospital where he was pronounced dead shortly after.

‘Lucas’ parents have been ‘consumed by grief’ over the death of their precious little son that day,’ Mr White said.

A week after Lucas’ passing the school newsletter stated he died ‘after an isolated medical episode related to his condition’, a statement which Mr White labelled ‘misleading’.

It was only when the five-year-old was asked if he needed to go to the bathroom that the teacher saw his eyes were glassy and knew something was wrong

A plaque was then placed outside the classroom where he choked to death, something the family weren’t consulted about.

Mr White made several recommendations that stemmed from the coronial inquiry including that all teaching staff should be required to have up-to-date qualifications in providing first aid.

It was also recommended that the department reviews its procedures and policy around the storage and consumption of food and beverages at school.