Kilvington Grammar School: Huge fines after student Lachlan Cook dies on school trip to Vietnam

A prestigious Melbourne school has been ordered to pay a huge fine following the death of one of its students during a school trip to Vietnam after teachers failed to provide appropriate medical support when he became seriously ill.

Kilvington Grammar School Ltd — where fees can be as high as $30,000 per year — was ordered to pay $140,000 in the Melbourne County Court on Wednesday over the death of student Lachlan Cook, a type 1 diabetic.

The school had earlier pleaded guilty to a single charge of failing to ensure people other than employees were not exposed to health and safety risks.

Tour provider World Challenge Expeditions Pty Ltd also pleaded guilty to the same charge and received a $150,000 fine.

Lachlan’s health took a turn for the worse about two weeks into the 2019 trip when he began vomiting, became extremely thirsty, and complained of abdominal pain, fast breath, sore ribs and low energy.

All are symptoms of diabetic ketoacidosis, which can be treated if identified early but is life-threatening if left too late.

He was an outstanding young man who was kind, compassionate and considerate of others.

The court was told that despite being aware of Lachlan’s diabetes, the three supervising adults on the trip – two teachers from Kilvington Grammar and an expedition leader from World Challenge – did not have the knowledge or training to recognise the warning signs as a serious complication.

The expedition leader contacted the World Challenge operations centre for advice but did not initially disclose Lachlan’s diabetes, which delayed a critical response, according to a statement released by WorkSafe Victoria.

“The following morning, Lachlan’s condition had significantly worsened, with his blood sugar level extremely high, and he was soon non-responsive.

“He was taken to a local hospital where he stopped breathing and went into cardiac arrest. Though resuscitated, he remained in a coma and was later transferred to the Royal Children’s Hospital in Melbourne, where he was declared brain dead.”

An autopsy confirmed that the cause of Lachlan’s death was diabetic ketoacidosis.

WorkSafe Executive Director of Health and Safety Sam Jenkin said Lachlan’s death was an avoidable tragedy.

“Working with children – especially children with health conditions – comes with extremely serious responsibilities,” Mr Jenkin said.

“Frustratingly, both the school and the trip provider knew Lachlan was diabetic and yet didn’t take steps to reduce the risk of illness or death by properly supporting their staff in identifying potentially serious health complications.”

A WorkSafe investigation found that while Kilvington Grammar had diabetes management and action plans for Lachlan which provided appropriate guidance on treating his diabetes, they were not taken on the trip.

An inquest into Lachlan’s death heard that having the plans on hand would have led to an earlier diagnosis of diabetic ketoacidosis.

“The school also failed to assign either of the teachers on the trip as Lachlan’s buddy and provide them with additional training or information from the school nurse, in line with a system that was in place for school trips at the time,” the WorkSafe statement read.

“The court heard that it was reasonably practicable for Kilvington Grammar to have reduced the risk of illness and death by providing at least one of the teachers on the trip with additional training and instruction for type 1 diabetes; and requiring the teachers to take Lachlan’s diabetes management and action plans with them to Vietnam.”

The WorkSafe investigation also found World Challenge did not provide any specific advice or additional training to assist with the expedition leader’s knowledge of diabetes.

“The company required the expedition leader to complete an online medical competency test before the trip, during which she was advised that disclosing pre-existing medical conditions when contacting the World Challenge operations centre was unnecessary.

“The court heard that it was reasonably practicable for World Challenge to have reduced the risk of illness and death by providing information, instruction and training to expedition leaders on type 1 diabetes; and instructing and training expedition leaders to disclose pre-existing medical conditions when contacting its operations centre for a medical issue.”

Principal Rob French said the school accepted its responsibility for its role in the events leading up to Lachlan’s death, describing it as “a truly devastating and unimaginable outcome”.

He said since the trip, the school had put in place practices to ensure the safety of students and staff, including staff training in the management of a number of health conditions, including diabetes.

“Nothing can alter the fact, however, that Lachie passed away in tragic circumstances on the Vietnam trip in 2019.

“On behalf of the school, I offer my deepest apologies to Lachie’s family and friends for their devastating loss. Our thoughts and prayers remain with them today and always.

“We will continue to honour Lachie’s memory. He was an outstanding young man who was kind, compassionate and considerate of others. He lived with courage and determination in the face of adversity, displayed genuine leadership qualities, was warm-spirited, inclusive of others and a greatly respected member of our community.”

World Challenge managing director Peter Fletcher said the business was constantly reviewing and updating its health and safety procedures and remained committed to ensuring school trips were safe and inclusive as they could be.

“Our thoughts have been with Lachlan’s family and friends since this tragic accident in 2019, and Lachlan will forever be in our hearts.”