AN INQUEST INTO THE DEATH OF CHRISTIAAN ADRIAAN ROODT

Contributing factors

• Inadequate risk assessment and management plan not completed despite off-school activity
• Insufficient supervision ratios for bushland terrain with poor visibility and sightlines
• Activity not formally approved by school principal or education directorate
• Absence of formal training for teachers on risk management policies and procedures
• Unclear policy categorization creating confusion about which requirements applied
• Difficult terrain making continuous visual supervision of students impossible
• Gaol area not visible to supervising teachers
• Students engaged in unsupervised mischievous behaviour (log-lifting) due to boredom while detained in gaol
• Multiple policy documents with overlapping and conflicting requirements

Coroner's recommendations

1. That cohorts of teachers be prioritised for professional development in respect of risk assessment generally, as well as on relevant policies and procedures and the expectations of them
2. That the ACT Education Directorate take steps to evaluate the success of the implementation of the Taskforce's recommendations, particularly in relation to enhancing risk assessment capability within the teaching ranks, and publish the outcome of that evaluation within twelve months
3. That the Attorney-General review the operation and application of WHS law to the ACT Education Directorate to ensure that children and staff are kept safe
4. That the Directorate review its policies on physical activities and excursions with a view to compliance with the Safe Work Australia How to Manage Work Health Safety Risks Code of Practice and report to the Attorney General about whether their policies comply with the Model Code adopted by the ACT Government
5. That the Directorate develop policies that foster ongoing work health and safety training and report to the minister on the development of those policies within 12 months
6. That the Directorate develop policies that foster ongoing work health and safety compliance responsibility and auditing within the Directorate and report to the minister on the development of those policies within 12 months