Finding into death of Alexander Sheng Wei Li

Contributing factors

• exposure to extreme ambient temperatures (39.1°C at point of collapse, 36.1°C at lunch)
• sustained strenuous physical activity (14km bushwalk with 17kg pack) in extreme heat without adequate acclimatisation
• underlying enterovirus D68 infection causing fatigue and potentially pyrexia
• inadequate weather monitoring during activity
• remote location with delayed access to medical care (42km from nearest ambulance station)
• lack of detailed pre-activity briefing on heat illness risks and management
• unrecorded asthma history not communicated to expedition staff
• absence of heat stress management guidelines and protocols
• insufficient breaks and activity duration for extreme temperatures

Coroner's recommendations

1. Hold the Plumbago experience during periods of lower/milder heat and not during peak summer conditions
2. Update Student Preparation booklets to reflect dangers of heat stroke, heat exhaustion and dehydration and ways to manage these conditions; students and parents should be thoroughly briefed on these dangers prior to and during the camp
3. Parents/guardians should be fully advised of the risks of the expedition prior to signing a consent form
4. Staff should utilise communication equipment to check on current weather forecasts prior to each day's activities and periodically throughout the day, and amend activities accordingly
5. Adopt immediate procedures providing more accurate guidelines for heat stress management during such activities, including consideration of Sports Medicine Australia Hot Weather Guidelines recommending: activity duration limited to less than 60 minutes per session for temperatures 31-35°C with relative humidity exceeding 50%; and postponement to cooler conditions when temperatures reach 36°C and above with humidity of 30% and above