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

The parents of a schoolboy who choked on a nectarine stone have criticized the Ministry 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 when he choked on a piece of fruit.

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

On Friday, a report on his death showed that it was preventable.

SA Deputy Coroner Ian White criticized the school, saying staff had not received adequate first aid training.

Outside court, his parents Daniela Mazzei and Miguel Latouche gave an emotional speech on Friday criticizing the education ministry’s handling of their son’s death.

“Obviously, the Education Department didn’t know or want to know how a young boy died in their care,” his mother told reporters out of court.

“They weren’t interested in learning about his death to make sure this never happened again.

“The school’s very first communication about his death was insincere and our approach to the then principal was basically ignored.

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

“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 searching for answers since the day their son died and described the lack of information 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 alone without supervision,” the family said.

On the day Lucas died, he was away from his classmates because his teachers feared he was at risk of swallowing objects during a science class.

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

While there, he found a nectarine, which he ended up choking on.

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

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

“Lucas was left unsupervised for an unacceptable amount 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 wasn’t until the five-year-old was asked if he needed to go to the bathroom that the teacher saw his eyes glazed over and knew something was wrong.

In the moments that followed, teachers unsuccessfully tried to save his life by pounding on his back, even lifting him by his feet so that he was upside down while staff beat his back.

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

“Lucas’s parents are ‘devastated with grief’ over the death of their precious little boy that day,” Mr White said.

A week after Lucas’ death, the school newsletter stated that he died “following an isolated medical episode related to his condition,” a statement Mr White labeled “misleading.”

Subsequently, a plaque was placed outside the classroom where he choked, something the family was not consulted about.

Mr White made several recommendations resulting from the corona inquiry, including that all teaching staff should have up-to-date first aid qualifications.

It was also recommended that the department review its procedures and policies around the storage and consumption of food and beverages in the school.