Coroner's Finding: SCHULZ Sophie Ann
Deceased
Sophie Ann Schulz
Demographics
1y, female
Date of death
2009-06-17
Finding date
2013-05-14
Cause of death
Head injuries from crush force caused by hydraulic massage table lowering mechanism
AI-generated summary
An 18-month-old girl died from crush injuries to her head when trapped in the hydraulic lowering mechanism of a massage table at a private clinic. The child moved unobserved into the gap beneath the table while it was being lowered by a therapist, causing instantaneous fatal injuries. The coroner found that the therapist failed to account for the child's location before operating the table and did not maintain adequate vigilance. The mechanism was recognized as dangerous, with foreseeable risks to small children. The clinic lacked explicit safety protocols for children in treatment rooms, and staff had not been adequately trained on preventive measures. Key preventable factors included lack of child supervision requirements, absence of mechanical guards on the table, and inadequate safety communication to both staff and patients.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- Failure of therapist to account for child's location before operating table
- Inadequate vigilance during table lowering operation
- Lack of explicit safety protocols requiring children to be supervised by persons other than patients
- Absence of mechanical guards on exposed lowering mechanism
- Inadequate communication of hazards to staff and patients
- Clinic culture tolerating presence of unattended young children in treatment areas
- Absence of written safety instructions and regular safety reminders to staff
- Therapist unaware that child had moved under table
Coroner's recommendations
- These findings be drawn to the attention of Standards Australia with a request to research and implement a Standard requiring guards on massage tables with exposed lowering mechanisms to prevent accidental access to working mechanisms
- SafeWork SA issue a further Safeguard stating that children should not be permitted within rooms containing massage tables of this kind, except age-appropriate children accommodated within playpens
- Consideration of legislative reform to allow coronial witnesses to be compelled to answer incriminating questions with certificate protection against use of evidence in subsequent proceedings, similar to NSW model
Further listening
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