'I don't think we're ever going to know why he did that': no one to blame in ... - Sydney Morning Herald

Nut allergy ... Raymond Cho. Photo: Supplied

Raymond Cho's tragic death was the result of the "small things that add up to a tragedy" and no one was to blame, a coroner has found.

Raymond Cho collapsed after he ate a walnut biscuit baked by a friend in a cooking class at Ashfield Boys' High School on May 19 last year.

He was taken to hospital, but died after he was taken off life support on May 24.

The inquest examined evidence about delays in an ambulance being called to the school, some problems a teacher had with giving Raymond an adrenaline injection, and whether CPR should have been administered before paramedics arrived.

It also looked at why nuts had been used in a cooking class at school, though the teacher had warned students about the risk of severe allergies.

State Coroner Mary Jerram assured the staff at the school and the boys' family that they were not to blame.

"Of course you're going to go on grieving. It's not something you should blame yourself for. It's just sad," Ms Jerram said to the family.

She said the staff who went to his aid at the school had "the best wills in the world".

Raymond took the biscuit from his friend and had a bite, despite walnuts having been mentioned, she said.

"I don't think we're ever going to know why he did that."

Ms Jerram made three recommendations to the education minister, including that nuts be restricted in schools and eliminated from cooking classes.

She also recommended that students with asthma or allergies be actively encouraged to carry their own EpiPens, which deliver a rapid dose of adrenaline, or their ventilators.

She said the department should continue to improve training in anaphylaxia, especially face-to-face training.

Ms Jerram had heard evidence that restricting nuts at schools was more effective than banning them, because bans could make students and staff complacent about the risks and be lulled into a false sense of security.

At the beginning of the inquest, Michael Fordham SC, representing the NSW Department of Education and Communities, said a number of changes had already been made to prevent a similar tragedy.

Those changes included training in anaphylaxis and emergency care for all school staff.

"It was believed prior to Raymond's death that the department had in place proper systems to keep children with anaphylaxis safe, but this was wrong," Mr Fordham said, reading from a statement from the department's Director-General Michele Bruniges.

"These systems failed Raymond, the people at the school that day who tried to save him and yourselves."

The family's lawyer, Courtenay Poulden, said the family was grateful for how compassionate the coroner and everyone involved in the inquest had been.

"What's been identified this week is that there have been some problems and shortcomings in the way that serious medical problems are dealt with in schools," Mr Poulden said outside the court.

"The family's great hope is that what's happened to Raymond won't be in vain and that some of the improvements and suggestions the coroner made in the future provide assistance to others and this type of tragic event won't happen again."