The family of a 17-year-old student who died after playing a school game at Mount Ainslie hopes the recommendations from a coronial inquest into his death will prevent another student from being injured while outdoors and under the care of a school.
Christiaan Adriaan Roodt, who preferred to be called Adriaan and had been living in Yass, died in hospital on 18 October 2018.
The Campbell High School student had been playing a game called Capture the Flag near Mount Ainslie earlier that day when he had been struck in the head by a six-metre, 185 kg log.
Coroner James Stewart ultimately found that the inadequate processes and procedures at the school and the ACT Education Directorate constituted a matter of public safety.
“I find that with greater supervision, Adriaan’s death was preventable,” he said.
Capture the Flag was played at the mountain’s Remembrance Memorial Park, which contained trees and rocks, he wrote in his published findings for the inquest.
Five teachers had been supervising on the day, although Coroner Stewart said the terrain meant it was not possible for teachers to see all students at all times. None of them saw the incident that caused Adriaan’s injuries.
During the game, a group of students saw the large log and decided to try to pick it up. But as they pushed part of it above their heads, it began to slip out of their hands. When the log fell, it hit Adriaan on the head.
Coroner Stewart said before a game started, the school’s teachers would do a risk analysis at the site to see if anything was unsafe and there had never been a significant incident during a game before.
But he also noted Campbell High had no risk assessment for school activities at Remembrance Memorial Park or for Capture the Flag, nor had the school’s principal formally approved the game.
Coroner Stewart found the relocation of the game to the park changed its nature and how it was to be played. It meant it needed different guidance material and requirements that were “beyond those for mere classroom activities”.
He found a risk assessment and management plan should have been completed as the game was “very obviously a physical education activity” and was not held at school.
Also, he said the risk of a student being injured by the natural environment within the park while playing the game was not known to the school’s staff because they didn’t have such a plan.
“The risk assessments that had been completed were cursory and unwritten and failed to properly assess and appreciate all foreseeable risks, including the risk of mischief and misbehaviour associated with bored teenage boys,” Coroner Stewart said.
But he also said the uncertain nature of how Capture the Flag was defined “created an almost impossible maze of policy for the teachers to navigate”.
“Because there were differing requirements under each activity’s relevant policy or procedure, without knowing how the activity fitted into this policy maze, the teachers were not able to define what requirements were to be followed,” he said.
“This demonstrates, prima facie, the inadequacy of the guidance material that was in place in 2018.”
He did not criticise any individual teacher and commended the ACT Education Directorate for its proactive work on policy since Adriaan’s death.
However, he did find the supervision strategy of only using the existing teachers to monitor a game at Mount Ainslie without more support was inadequate, saying it was “a failing of Campbell High School and the Directorate”.
He made several recommendations, including prioritising professional development on risk assessment and relevant policies for teachers, and that the Directorate review its policies on physical activities and excursions.
In a statement, Adriaan’s mother Sandra Roodt said it had taken four-and-a-half years to reach this point, and her family was grateful the coronial process was over.
“We believe we achieved the outcome we wanted to achieve,” she said.
“We wanted to ensure a thorough investigation into the circumstances leading to Adriaan’s accident and consequent death.
“Now we can only hope that these recommendations, when implemented, will prevent another child sustaining an injury during an outdoor education session and whilst in the care of a school.”
She said her family was thankful the ACT Education Directorate had already implemented many recommendations.