Coroner Audrey Jamieson today released the findings of her inquest into the death of Canterbury teenager Nathan Francis, who died after eating food containing nuts at a school cadet camp.
The findings came five years after Nathan, who was in year nine at Scotch College at the time, died after eating a peanut satay meal at the camp in Victoria’s Wombat State Forest in March 2007.
Ms Jamieson’s report found the death occurred despite Nathan’s mother, Jessica Francis, complying with a school requirement to provide written notification of any allergies.
It stated that Nathan’s death was directly related to Scotch College’s failure to take “reasonable steps” to ensure the health and safety of the boys attending the camp.
“I accept that the Scotch College teachers failed to comprehend the seriousness of peanut allergy in March 2007 and that since mid-2008, the level of legislative, documentary and public awareness has greatly improved,” Ms Jamieson said in her report.
The report made five recommendations intended to protect students with food allergies, including:
- The Department of Education and Early Childhood Development review the 2006 Anaphylaxis Guidelines for Victorian Government Schools to ensure the content and advice to schools reflects best practice in anaphylaxis management
- The Department of Education and Early Childhood Development provide guidance to all Victorian schools about purchasing spare or “back-up” adrenaline auto-injection devices for first-aid kits
- The Minister for Education introduce a requirement for all schools to complete an annual Anaphylaxis Risk Management Checklist
- If the previous recommendation is not feasible, the 2006 Anaphylaxis Guidelines for Victorian Government Schools be revised to include an Anaphylaxis Risk Management Checklist.
- Scotch College revise its action management plans to incorporate strategies to prevent exposure to allergens both in and outside school settings
Nathan’s father, Brian Francis, today welcomed the recommendations but warned they must be acted upon to prevent further deaths.
“The inquest into Nathan’s death can not be another wasted opportunity to save lives,” Mr Francis said.
“If it can lead to broader community awareness of how allergies can result in death, lives will be saved. If it can lead to the introduction of new measures to prevent this happening again, that will bring us some comfort.”
Mr and Mrs Francis reached a confidential settlement with Scotch College and the Australian Defence Force, which supplied the ration packs containing nuts, prior to the inquest beginning 18 months ago.
In addition, the Australian Army was fined $210,010 in June 2009 over its role in Nathan’s death.
Scotch College was not fined as it is not covered by the same laws.
Slater and Gordon Public Liability National Practice Group Leader Barrie Woollacott also welcomed Ms Jamieson’s findings, but said consideration needed to be given to strengthening existing laws to ensure that any organisation whose actions lead to the deaths of food allergy sufferers are prosecuted and fined.
“Any system or management plan to safeguard individuals with serious allergies will fail unless people act on those plans and make them work,” Mr Woollacott said.
“Five deaths since Nathan’s death suggest that organisations are not getting the message.”
“If preventing another death of a child in their care is not enough incentive, then perhaps schools and organisations need the same threat of financial penalty or criminal charges to encourage them to keep allergy awareness at the top of the safety list,” Mr Woollacott said.
Here is a full transcript of Brian Francis’s statement outside the Coroner’s Court today:
Nathan was a wonderful, vibrant and loving boy who touched the lives of all around him.
Nathan was our eldest son and the first grandchild in the family. He was very special and loved by us all.
To say Nathan’s death has devastated our lives is too simplistic and understates how this horror has torn through our family. We will always continue to grieve his loss.
We have, however, with love and support of family, friends and the Scotch CollegeCommunity, started to rebuild our lives and look forward to happier days ahead.
Scotch College could have so easily prevented Nathan’s death.
In 2007, at the time of Nathan’s passing, Scotch College had no awareness, understanding or procedures to protect children with life threatening allergies.
At the time of Nathan’s death, Coroner Jamieson was conducting an inquest into the death of Alex Baptist, a 4-year old with peanut allergy who suddenly died whilst at kindergarten.
If Scotch College and other schools had learnt any lessons from that tragedy, I would not be standing here today and Nathan would now be studying at university.
The sad truth is that, since the 2007 Scotch Camp on which Nathan died, there have been at least 5 other teenagers who have lost their lives across Australia from allergic reactions. All of these deaths were preventable.
In the 18 months it has taken for these findings to be delivered, yet another young boy, Raymond Cho, lost his life to anaphylaxis while at school.
The inquest into Nathan’s death can not be another wasted opportunity to save lives. If it can lead to broader community awareness of how allergies can result in death, lives will be saved. If it can lead to the introduction of new measures to prevent this happening again, that will bring us some comfort.
Allergic reactions are not just a rash, itchiness or feeling unwell, they can and do cause death.
We want the facts and mistakes of Nathan’s case to not only be known but to serve as a warning siren to others.
Allergies are not just about the individual involved, they impact on entire communities.
This must never happen again. Through Awareness, Avoidance and Action no other child should lose their life.