An inquest into the death of a young boy at an Adelaide school has found that the first aid response was "hampered by panic and communication difficulties".
As such, it has raised questions about whether South Australian teachers are aptly equipped to deal with first aid emergencies.
The tragedy unfolded when five year-old Lucas Mazzei choked to death in a special needs classroom at Henley Beach Primary School.
Lucas was sitting in the school's special needs classroom on his own. His classmates had departed for a science lesson. Lucas was unable to join them, as it was widely known that he would put "anything and everything" in his mouth due to his global developmental issues.
The teacher supervising Lucas also left the classroom at one point, and the support staff person did not have a line of sight. While he was unobserved, Lucas began choking on a nectarine stone.
As soon as staff became aware, they called for an ambulance and started first aid. While waiting for the ambulance, attempts were made to clear Lucas's airway by banging him on the back, holding him upside down, and placing him in the recovery position.
Some of the first aid provided was not in accordance with the guidelines recommended by the Australian Resuscitation Council. Likewise, CPR did not commence until after an ambulance arrived. And though a defibrillator had been brought into the classroom at one stage, it was still in its packaging.
Lucas was subsequently taken to the Women's and Children's Hospital, where he was pronounced dead.
The inquest is currently before Deputy Coroner Ian White. Counsel assisting the coroner, Emma Roper, told the inquest that all staff provided first aid to the best of their ability and were not to be criticised.
However, she acknowledged that there had been a delay in commencing resuscitation. "No chest thrusts were performed by the staff present," she said. "This was despite the fact that they had all had first aid training as recently as February and chest thrusts were part of that curriculum."
"It appears that the provision of first aid, in accordance with the instructions of the [triple zero] operator was hampered by panic and also communication difficulties." Ms Roper advised that the panic was so great that one of the staff members had to leave the room "because she was overcome with emotion".
In South Australian schools, a certain number of designated first aid staff are required. However, public school teachers are not required to have up-to-date first aid training.
"At the time of Lucas's death," Ms Roper told the inquest, "none of the persons present had completed the course specifically designed for people working with children. The Department for Education did not, and does not, require this level of training to be undertaken by teachers in public primary schools."
Professor Richard Bruggemann, an advocate for Lucas's family, said Lucas's parents wanted answers and to ensure no other child dies in similar circumstances.
"A young boy has died on his third or fourth week at school. Five years later, the family don't know how that happened," he said. "They equally don't know that this won't happen to another child."
"It's taken the family, his pro bono lawyers who have been working with them, me as a sort of amateur advocate, to get this onto the agenda. The really good thing about coronial reports is that they give us information about how to ensure how these things never happen again."
As a nationally registered training organisation, Australia Wide First Aid would encourage anyone working in education and care settings to waste no time enrolling in an accredited first aid course.
Being properly prepared can save lives.