Coroner's Finding: Paul Phillip Mathew Carpenter
Deceased
Paul Phillip Mathew Carpenter
Demographics
11y, male
Date of death
2009-09-16
Finding date
2011-06-24
Cause of death
Comminuted fractured skull with cerebral oedema from being run over by the rear passenger side wheels of the school bus
AI-generated summary
Paul Carpenter, 11, died from blunt force trauma after falling under a school bus while "bus surfing" (hanging onto the emergency footrest) at a bus stop in Junee, NSW. The coroner found this dangerous behavior occurred regularly among students, with episodes witnessed by bus driver Mr. Hollis. Although aware of the practice and warning some children, Hollis failed to report it to the bus company owner, school, or parents. The bus company lacked adequate safety management systems to address behavioral risks, and the emergency footrest design was dangerously easy for children to grip. The coroner concluded some things should have been done differently—particularly reporting the behavior to parents and school—though full reporting might not have prevented Paul's death. However, reporting would have given parents an opportunity to intervene. Recommendations focus on developing bus safety curriculum in rural schools and redesigning emergency footrests.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Bus driver aware of risky behavior but failed to report to company owner, school, or parents
- Bus company lacked adequate safety management system addressing behavioral risks
- Emergency footrest design made it easy for children to grip and hang on
- Children engaging in dangerous behavior deliberately and covertly
Coroner's recommendations
- Department of Education and Communities to liaise and consult with Department of Transport, Bus Safety Advisory Committee and other stakeholders to develop bus safety awareness curriculum element in schools in rural and regional areas of NSW, particularly addressing bus surfing and activities involving hanging on to, climbing on to, or being dragged along by a moving bus or vehicle
- Department of Infrastructure and Transport to revise design rules as a matter of urgency to ensure that external emergency footrests less than 1500mm above ground are designed so that it is not possible to fully wrap fingers around the footrest
Full text
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