A 16-year-old boy with a nut allergy who died after eating a walnut biscuit at a Sydney school was tragically let down by the NSW education department systems meant to protect him, an inquest has heard.
Raymond Cho went into anaphylactic shock after he ate the biscuit baked by other students in a cooking class at Ashfield Boys' High School on May 19, 2011.
He was taken to hospital, but died after he was taken off life support on May 24.
At the Glebe Coroner's Court on Monday, State Coroner Mary Jerram was told the education department and staff were aware that Raymond suffered from anaphylaxis and asthma.
But other students shared the biscuits they had baked in a cooking class, the inquest heard.
Raymond fell ill later in a maths class and went into anaphylactic shock. He was was treated by the use of two epipens, which are used to quickly inject a dose of adrenaline.
Michael Fordham SC, representing the NSW Department of Education and Communities, read Raymond's family an apology from the department's director-general, Michele Bruniges.
"Dr Michele Bruniges ... was deeply saddened when she learnt of Raymond's tragic death. She wishes to unreservedly apologise on her own behalf and on behalf of the many people working in public education for the unimaginable hurt and anguish you and your family have suffered as a result of his loss," the statement from Dr Bruniges said.
"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.
"These systems failed Raymond, the people at the school that day who tried to save him and yourselves.
"It will be small consolation to hear that the department has reviewed its systems and has made a number of significant changes since Raymond's death."
Those changes included compulsory training in anaphylaxis and emergency care for all school staff and a requirement that every school run CPR courses on an annual basis.
The department is also continuing to look at how it can improve safety and well-being of students with anaphylaxis.
"The director-general hopes that this inquest helps your family, and other families who have children with anaphylaxis, by identifying where things went wrong, examining what has been done to date in response and considering whether anything further can be done to reduce the chance of another tragedy like Raymond's death occurring in the future."
Raymond's family are at the inquest, holding pictures of the schoolboy.
The inquest, which will look into the school's policies and the use of epipens, continues.