Inquest into the death of Jethro Dhamarrandji-Baker

Contributing factors

• Absence of formal written risk assessment for the Troopy Pull activity
• Loss of institutional knowledge due to lack of handover when previous organiser departed
• Failure to implement safety strap separation between vehicle and rope used in previous years
• Insufficient distance between participating children and the vehicle
• Inadequate hazard identification by supervising staff
• Risk assessment conducted ad-hoc during the event by a participant rather than in advance
• Use of different vehicle without established safety setup procedures
• Knotted rope requiring improvised attachment to vehicle
• Driver unable to see the child or react in time to prevent collision

Coroner's recommendations

1. Formal written risk assessments should be undertaken for all non-routine school activities
2. Risk assessments should be documented and reviewed prior to each instance of an activity, not conducted ad-hoc during the event
3. Proper handover procedures should be established when staff responsible for safety protocols change
4. Safety mitigation measures from previous years should be documented and consistently implemented
5. Responsibility for safety oversight should not rest with a single person who is also participating in the activity
6. Schools should ensure full understanding of statutory duties under Work Health and Safety legislation