AN INQUEST INTO THE DEATH OF CHRISTIAAN ADRIAAN ROODT
[2023] ACTCD 5
•17 March 2023
CORONERS COURT OF THE AUSTRALIAN CAPITAL TERRITORY
Case Title: AN INQUEST INTO THE DEATH OF CHRISTIAAN ADRIAAN ROODT Citation: [2023] ACTCD 5 Hearing Date(s): 28 January 2022, 12 April 2022 Decision Date: 17 March 2023 Before: Coroner Stewart Decision: [3], [124], [127], [132], [139], [146], [151], [160], [164] – [167], [186], [189],
[195], [198] – [207]Catchwords:
CORONIAL LAW –– cause and matter of death ––student safety – activities conducted in bushland – adequacy of supervision – risk
assessment processes - matter of public safety Legislation Cited: Coroners Act 1997 (ACT) s52, s55, s58 Work Health & Safety Act 2011 (ACT), s155 Cases cited: Inquest into the death of OD Inquest into the death of XB Inquest into the death of SI Inquest into the death of IS Inquest into the death of LD
Inquest into the deaths of IU & BN Inquest into the death of Kyle VASSIL [2014] VicCorC 188 Inquest into the death of Jethro Ngalarra Dhamarrandji-Baker [2016]
NTLC 021Representation: Counsel Assisting Ms R. Curran
Ms S. Baker-GoldsmithCounsel for the Australian Capital Territory Ms V. Thomas Counsel for the Family Mr J. Ronald File Number(s): CD 258 of 2018 CORONER STEWART A. INTRODUCTION 1․ Master Christiaan Adriaan Roodt died in the Canberra Hospital on 18 October 2018. I will respectfully refer to him as Adriaan throughout these reasons – Adriaan is his preferred name. 2․ The timing and manner of Adriaan’s death was tragic and unnecessary. It has caused much grief to Adriaan’s loving family and the many people who also loved and knew Adriaan. 3․ There is no dispute in relation to the formal findings that I must make pursuant to s52 of the Coroners Act (ACT) 1997:
(a) The identity of the deceased was Christiaan Adriaan Roodt aged 17 years (DOB 17/09/2001);
(b) Adriaan died at the Canberra Hospital at 2.56 pm 18 October 2018; and (c) The cause and manner of death was circulatory failure caused by traumatic brain injury from being struck by a log during a physical
education activity.
[1] Exhibit A.20 (AFP brief), TROC Christiaan Roodt, p345-6
[2] Exhibit A.20 (AFP brief), TROC Christiaan Roodt, p346
[3] Exhibit A.31 (AFP brief),TROC MQ, p440 at A400[4] Exhibit B.13 & B.14 (WorkSafe brief), Student files for Christiaan Adriaan Roodt
B. FACTS 4․ The following facts are largely agreed between the parties. In this decision names of students (except for Adriaan), staff and witnesses have been anonymised for publication. I have also made an order supressing their names today. 5․ Adriaan resided in Yass, New South Wales (“NSW”) with his family, where they had been residing since 2009. Between 2007 and 2009, the family resided in the Australian Capital Territory (“ACT”) after having moved to Australia from South Africa.[1] 6․ Other than moving between nations, Adriaan had an unremarkable upbringing, with no major medical, social or education problems.[2] Adriaan was an enthusiastic boxer and capable sportsman. He was well liked by his peers. He was seen as “kind of just a good guy, I guess. He liked his boxing, and he was pretty good at soccer.” [3] 7․ In 2018 Adriaan was enrolled in Year 10 at Campbell High School. He had been attending the school since Year 7.[4] Campbell High School
8․ Campbell High School is an ACT public school for Year 7 to Year 10 students.[5] It is located on Treloar Crescent, Campbell ACT.[6] 9․ Campbell High School regularly used the Mount Ainslie area as a learning and resource space.[7] Remembrance Memorial Park is a dense bushland area accessible to the public and is located at the base of Mount Ainslie.[8] The park is about a 12 minute walk from Campbell High School.[9] [5] Exhibit A.2, Statement of F/C James, p2
[6] Exhibit A.2, Statement of F/C James, p2
[7] Exhibit B.30 (WorkSafe brief), TROC Educator 9, p2411
[8] Exhibit A.2, Statement of F/C James, p2
[9] Exhibit A.2, Statement of F/C James, p2
Excursion Consent
10․ It is Campbell High School’s standard practice that at the start of the year an excursion approval letter is requested from each parent.[10] It is in the following terms: [10] Exhibit B.30 (WorkSafe brief), TROC Educator 9, p2413 L40-p2414 L3
“I hereby consent to [my] child attending supervised school activities
approved by the principal. This consent covers all occasions during the time that [my] child is enrolled at this school, unless otherwise indicated in writing.
NOTE: This consent for your child’s attendance at school supervised
excursions is for those excursions which occur in the immediate vicinity of the school and generally involve movement on foot or bicycle. Specific
consent will be sought for all other excursions.”
11․ The most recent hard copy Student Information Check Sheet containing the General Consent on Campbell High School records for Adriaan was dated 18 December 2016.[11] [11] Exhibit B.13 (WorkSafe brief), Student files for Christiaan Adriaan Roodt, p1433
The Morning of 18 October 2018
12․ At about 7:20am on Thursday 18 October 2018 Adriaan departed his residence and attended Campbell High School.[12] 13․ At about 10:00am Adriaan attended the gymnasium for Physical Education (“PE”) class in accordance with the school curriculum. The PE class was scheduled in period 2 and for about one hour.13 14․ A decision was made for five classes of Year 9 and 10 students to play ‘Capture The Flag’ at the base of Mount Ainslie. It is unclear who specifically decided to play the game, but the idea was raised that morning amongst the teaching staff.[14] 15․ Five classes totalling about 112 students of students between Year 9 and Year 10 attended the gymnasium.[15] 16․ Five teachers were involved in supervising the students. For the purposes of publication of these findings they will be referred to as being Educator 1[16], Educator 2[17], Educator 3[18], Educator 4[19] and Educator 5.[20] [12] Exhibit A.20 (AFP brief), TROC Christiaan Roodt, p345, A35 13 Exhibit A.27 (AFP brief), Timetable for Adriaan Roodt, p371
[14] Exhibit B.27 (WorkSafe brief), TROC Educator 1, p2287 L33-44
[15] Exhibit B.27 (WorkSafe brief), TROC Educator 1, p2287 L33-44 & p2322 L28-41
[16] Exhibit B.27 (WorkSafe brief), TROC Educator 1, p2282-2326
[17] Exhibit A.16 (AFP brief), TROC Educator 2, p301-322
[18] Exhibit A.12 (AFP brief), TROC Educator 3, p220-252
[19] Exhibit B.26 (WorkSafe brief), TROC Educator 4, p2224-2281
[20] Exhibit A.17 (AFP brief), TROC Educator 5, p301-322
The Game
17․ ‘Capture The Flag’ is a game that has been played at a number of schools throughout the ACT Schools System for more than ten years.[21] It is a game where students are divided into teams and compete on an outdoor field to capture the opposing team’s ‘flags’. [22] 18․ Campbell High School has been running the game for over 10 years on at least a once a term, if not, monthly basis.[23] The game was described as part of Campbell High School culture.[24] A minimum of two classes are required to play with up to six classes playing at times.[25] 19․ The students who participated in the game on 18 October 2018 would have played it at the school previously.[26] 20․ Campbell High School students most often played this game off the school grounds at the Remembrance Memorial Park at the base of Mount Ainslie. However, it was also played at times on the school or the Reid ovals. [27] 21․ When it was played at Remembrance Memorial Park, the game was played on an established area of play that has been used over many years. The game field used in the area was approximately 400 metres long by 150 metres wide in size, and natural borders were used to delineate the zone. Specifically, the borders were constituted by a fire trail and main walking trail indicating external field boundaries, and power lines delineating the field halves.[28] 22․ There are no written rules for ‘Capture The Flag’. The game is played in an area of two halves. There are two teams, one occupying each half. Each team has a ‘base’ within their territory which contains ‘flags’. The aim of the game is for players to run into the opposing team’s territory, grab a ‘flag’ and return the ‘flag’ to the ‘base’ within their own territory without being tagged by the opposing team’s players. If a player is tagged in the opposing team’s territory, then that player must sit in the opposing team’s ‘gaol’ and wait to be rescued. Another member of a team can rescue a member of their own team from their opponent’s gaol by tagging them and escorting them back to their own team’s territory, in which case the rescued team member is back in the game.[29] The team which gets all of the opposing team’s ‘flags’ within its own ‘base’ wins. The duration of the game depends on the number of ‘flags’ involved. Two ‘flags’ can be used for a short game with a lengthier game involving up to eight ‘flags’.[30] 23․ The natural environment within Remembrance Memorial Park provided trees, rocks and flora located within the game field. They were used tactically by players to provide cover and hide from their opponents.[31] 24․ The following occurred each time the game was played: ‘[Teachers] do a risk analysis of the playing area each time that we go up there and the activity will be cancelled if wet, long grass etc. Anything that [the teachers] deem to be an unsafe environment to play in, the game is cancelled, and we will head to our adjacent oval to play’. [32] 25․ The teachers supervising the game would bring a first aid kit as well as their mobile phones.[33] 26․ The teachers regarded the game as popular with the students[34] who would often ask to play it.[35] 27․ There had never been a significant incident during the activity. [36] For the period in which Educator 4 had been conducting the activity, the only incident he could recall was when a student had seen a snake. The extent of the injuries had been a grazed leg.[37] Educator 4 could not recall any supervision issues that had arisen during the game other than students complaining of cheating.[38] Educator 1 said that he had not encountered any stupid or silly behaviour on previous occasions on which the game had been conducted. He said that the students were “quite responsible and mature” in the area.[39] There had never been any serious injuries. [40] [21] Exhibit B.28 (WorkSafe brief), TROC Educator 7, p2331 L17-20; Exhibit B.27 (WorkSafe brief), TROC
[22] Exhibit B.27 (WorkSafe brief), TROC Educator 1, p2282-2326
[23] Exhibit B.29 (WorkSafe brief), TROC Educator 8, p2375 L35-p2376 L2
[24] Exhibit B.30 (WorkSafe brief), TROC Educator 9, p2411 L23-29 & p2413 L3-16
[25] Exhibit B.2 (WorkSafe brief), Inspector Majer’s summary, p4, [4]
[26] Exhibit A.12 Educator 3 ROC p228 Q66[27] Exhibit B.26 (WorkSafe brief), TROC Educator 4, p2240 L16-20, p2258 L19-21, p2265 L19-24[28] Exhibit B.2 (WorkSafe brief), Inspector Majer’s summary, p4, [4]; also Educator 1’s maps, Exhibit B.27
[29] Exhibit .26 Educator 4 TROI, p2231 L15-20
[30] Exhibit B.2 (WorkSafe brief), Inspector Majer’s summary, p4, [1]-[3] – also as described by the various
[31] Exhibit B.27 (WorkSafe brief), TROC Educator 1, p2301 L28-29[32] Exhibit B.26, 2281, Educator 4’s document Capture The Flag – Safety briefing’; See also Exhibit B.26,
[33] Exhibit B.26, 2281, Educator 4’s document Capture The Flag – Safety briefing’; See also Exhibit B.26,
[34] Exhibit A.7, Educator 1 ROC,72 (answer to question 36), 87 (answer to question 222); Exhibit B.26,
[35] Exhibit A.16,Educator 2 ROC, 307 (answer to question 78).
[36] Exhibit A.10, Educator 4 ROC, 205 (answer to question 99).
[37] Exhibit A.7, Educator 1 ROC, 83, (answer to question 174) and 85 (answer to questions 189 - 192).
[38] Exhibit B.26, TROI Educator 4, 2244, lines 35 - 40.
[39] Exhibit B.27 TROI Educator 1, 2301 (lines 40-45).
[40] Exhibit A.7, Educator 1 ROC, 85 (answer to questions 188 - 192); Exhibit A.10, Educator 4 ROC, 205
The Safety Briefings
28․ In the gymnasium, Educator 1 conducted a verbal safety briefing to the students, which is standard practice. This briefing included the following:
(a) explaining rules of the game; (b) how to play; (c) safety rules which include no running fast through bushland, don’t pick up rocks or sticks, don’t pick up anything off the ground, leave the environment as it is,
be aware of surroundings and notify teachers of any wildlife located;[41] and
(d) that any silly behaviour is to be reported and students will be “sat out” with the teacher. [42]
[41] Exhibit B.27 (WorkSafe brief), TROC Educator 1, p2289-90 generally; also Exhibit B.26 (WorkSafe
[42] Exhibit B.26, 2281, Educator 4’s document ‘Capture The Flag – Safety briefing’.
29. It was usual practice for the teacher providing the briefing to seek confirmation from
other teachers that all relevant matters had been covered.[43]
[43] Exhibit A.12, Educator 3 ROC, 229 (answer to question 75).
30. After conducting the briefing, the five teachers escorted the students, on foot, to the
Remembrance Memorial Park area.[44]
[44] Exhibit B.27 (WorkSafe brief), TROC Educator 1, p2290 L20-29
31. Educator 1 provided a second safety briefing before he and Educator 3 carried out a
sweep of the play area. Instructions were also provided about the setting up of the
‘bases’ and ‘gaols’. The students then selected their ‘bases’ and ‘gaols’ and the game
commenced.[45]
[45] Exhibit B.27 (WorkSafe brief), TROC Educator 1, p2290-1 generally; also Exhibit B.26 (WorkSafe
32. I note the contrary evidence from Educator 5 who was asked if a briefing was given.
She said ‘…we didn’t today. We just gave them their stuff and sent them off’.[46]
[46] Exhibit A.6 ROC Educator 5 p8
33. Commencement of the game was signalled by one of the teachers blowing by a
whistle.[47]
[47] Exhibit B.27 (WorkSafe brief), TROC Educator 1, p2290 L42-45
Game Supervision
34. The five teachers monitored the game as it progressed. From time to time the teachers were involved in dealing with particular students or incidents rather than supervising the game generally.[48]
[48] For example Exhibit B.27 (WorkSafe brief), TROC Educator 1, p2291 L12-19
35. The five teachers moved within the game field during the game but were generally located at particular observation points so as to try to provide coverage and monitoring of the whole area.[49] Specifically:
[49] Exhibit B.27 (WorkSafe brief), TROC Educator 1 p2293 generally, also p2301 L34-37:
(a) By the time of the accident, Educator 5 and Educator 4 were located on the northern boundary of the ‘Capture The Flag’ area, being the high track at the
point where it intersects with the powerline mowed area.[50] Educator 4 had
[50] Educator 1’s maps, Exhibit B.27 (WorkSafe brief), p2325-6; Exhibit A.17 (AFP brief), TROC Educator
been at the bottom of the area at the beginning of the game and later made
his way up the field to join Educator 5.[51]
[51] Exhibit A.10, Educator 4 ROC, 198 (answer to question 22); Exhibit B.26, Educator 4 TROI, 2229-
(b) Educator 2 was located on the southern boundary of the ‘Capture The Flag’ area, being the lower track at the point where it intersects with the powerline
mowed area;[52]
[52] Educator 1’s maps, Exhibit B.27 (WorkSafe brief), p2325-6; Exhibit A.16 (AFP brief), TROC Educator
(c) Educator 3 was in the powerline mowed area in between the northern and southern boundaries, somewhere in the middle and perhaps closer to the
southern boundary;[53] and
(d) Educator 1 was in bushland to one side of the powerline mowed area towards the southern boundary.[54]
[53] Exhibit A.12 (AFP brief), TROC Educator 3, p222 at A16:
[54] Educator 1’s maps, Exhibit B.27 (WorkSafe brief), p2325-6
36. The ‘gaol’ area was not within sight of the supervising teachers due to the incline of
the hill[55] and the dense bushland.[56] The terrain and natural environment of the game
area meant that it was not possible for the teachers to have ‘eyes on’ all students at
all times.[57] There was no constant supervision or monitoring of the ‘bases’ and in
particular no specific monitoring of the ‘gaol’ areas.[58] Students took advantage of the environment to hide from other students as part of the game.[59] A mitigation strategy
adopted by the teachers was to move around and actively supervise the area.[60]
[55] Exhibit A.7 (AFP brief), TROC Educator 1, p84 at A179-80
[56] Exhibit A.7 (AFP brief), TROC Educator 1, p72 at A38
[57] Exhibit B.27 (WorkSafe brief), TROC Educator 1, p2301 L26-29
[58] Exhibit A (AFP brief), Item 16, Annexure M, TROC Educator 2 at p311 A132:
[59] Exhibit B.27 (WorkSafe brief), TROC Educator 1 at p2323 L23-28:
[60] Exhibit B.27 (WorkSafe brief), TROC Educator 1, p2301 L34-37
37. Educator 5 saw Adriaan and another boy who was involved in the incident, TC, together
sitting on a rock before the accident. She approached them and told them to get involved
in the game.[61]
[61] Exhibit A.17, Educator 5 ROC, 335 (answer to question 119).
38. No teacher directly observed the incident which caused Adriaan’s injuries, although
Educator 1 speaks of hearing a “scream” and that a bunch of boys came running.[62] No
teacher gives evidence of having witnessed any attempts to pick up the log. Had any
teacher observed students picking up a log, or attempting to pick up a log, they would
have intervened to stop the students.[63]
The Incident
[62] Exhibit A.7 (AFP brief), TROC Educator 1, p70 A14
[63] For example: Exhibit B.27 (WorkSafe brief), TROC Educator 1 at p2301 L42-44:
39. At about 10:45am, during play but towards the end of the game, Adriaan was in a
‘gaol’ area on the north-eastern side of the game field near the main walking trail. He
was ‘in ‘gaol’’ along with students TC (16 years old) and SC (16 years old).[64]
[64] Exhibit A.13 (AFP brief), TROC SC (Part 1), p255 at A19:
40. Around that time, they noticed a dead tree on the ground nearby within or just outside
the ‘gaol’ area, described as a log.[65] At all times the log was within or close to the
playing boundaries of the game, and the ‘gaol’ area was inside the playing boundaries
of the game.[66]
[65] Exhibit A.32 (AFP brief), TROC EM at p464:
[66] Educator 1’ s maps, Exhibit B.27 (WorkSafe brief), p2325-6
41. The log was later measured by Police to be 6.03 metres long and 188.5 kilograms in
weight.[67]
[67] Exhibit A (AFP brief):
42. TC reported that he and SC first picked up the log, but he is not sure whose idea it
was between them.[68] SC reported that TC was encouraging everyone to pick up the
log, but that they all voluntarily picked it up.[69]
[68] Exhibit A.6 (AFP brief), TROC TC, p52 at A49
[69] Exhibit A.13 (AFP brief), TROC SC (Part 1), p255 at A19
43. Sometime after the first attempts, students EM (15 years old), KN (16 years old) and
OP (16 years old) arrived and met with the other students at the log in or near the
‘gaol’ area.
44. Several students gave evidence of multiple attempts to pick up the log. The timing of
these attempts and the time over which this occurred is not clear from the evidence.
45. TC told Police that the incident occurred on the third or fourth attempt at lifting the tree.[70]
He said:
“So, at first, me and SC started lifting it, and then Adriaan started helping us … and
then we put it down, and that’s when OP and that turned up and we all did it together.”[71]
[70] See Exhibit A.6 (AFP brief), TROC TC, p56, referring to the incident occurring on the third or fourth
[71] Exhibit A.6 (AFP brief), TROC TC, p53 at A58-59
46. SC told Police:
“… me and TC saw this branch that we – he thought we could lift up. And then we tried
it individually and that didn’t work out. Um so then – I don’t know – we all just sat down
and said, “What’s the point of this? There’s just no point in doing it.” And then TC kept
bugging us to do it. So we all just jumped on and decided to try and lift up and flip over
this branch that was pretty big.” [72]
[72] Exhibit A.13 (AFP brief), TROC SC (Part 1), p255 at A19
47. EM wrote a handwritten account of the incident later that same day. In that document
he referenced four attempts at picking up the log.[73] He said that beforehand he, SC,
TC and Adriaan were:
“… waiting in the jail. TC was making jokes and he began lifting the log by himself….
SC then began trying to lift it by himself…. afterwards they both began trying to flip it
so they asked Adriaan …then asked me… Adriaan started lifting so I began too…they
shouted letting me know to get out of the way as they dropped down almost getting my
foot… soon after that EM, OP and MQ came they were asked to come and the other
guys felt confident that they would be able to flip it if the other guys joined (maybe
excluding one) and began to lift it the log.” [74]
[73] Exhibit A.32 (AFP brief), TROC EM contemporaneous (1.5-2 hours later) handwritten statement which
[74] Exhibit A.32 (AFP brief), TROC EM contemporaneous (1.5-2 hours later) handwritten statement at
48. EM also stated to Police:
“TC… went to go, um – found this log and he was, like, trying to just lift it up above and
see how high he could lift the log … then he was like ‘Oh yeah, um, pretty heavy’ and
stuff. Just laughing and stuff. Having a fun time. And then SC tried to lift it. And he got
it, ah, above – I think above his shoulders, but he wanted to get it higher and stuff. And
then TC was like “Yeah, do you boys want to come and see how high we can lift it?”
and so Adriaan and SC went to go lift it. And then I joined in shortly after at the front.
And then we just tried to lift it up and then it dropped down after we were getting a bit
tired … then … OP, MQ and JX came. And um they’ve just came in and the boys were
like “Yeah, um, go and see, ah, if you can lift the, ah – lift the log up” and so they all
came in. Started talking, you know, having a laugh. And then we all – we were all up there, um, trying to push the log up. Just to try and, um, flip it, I think, was – was the
purpose.[75]
[75] Exhibit A.32 (AFP brief), TROC EM p44-46 at A33-42
49. TC, SC, OP, EM, and Adriaan then stood at one end of the log and began to lift it up,
extending their hands above their heads. As they pushed the log up at an angle greater
than 45 degrees to the ground, the log began to slip. TC, EM, and SC moved to the
right of the log, as EM and OP moved to the left. Adriaan did not move from his position
underneath the log. The log fell and struck Adriaan on the left side of his head above
his ear, which caused Adriaan to be knocked unconscious.
50. TC told Police:
“We all sort of lifted it up above our heads, just moving down – just sort of sat it up
straight. And then it started tilting, so we said, “Get out of the way.” And they went
away, and Adriaan was starting the other way, so I pulled him because he wasn’t
moving. And it sorts of clipped the side of his head – top of his head and then he
fell on the ground and started bleeding out his ear …”[76]
[76] Exhibit A.6 (AFP brief), TROC TC, p47-48 at A15
“So we lifted it and we all sort of just edged against one of the trees so it could
topple over, and we all lifted it. All of us were there. And then, um, it started angling
off to the side and starting to fall, so I think someone hopped away, and it started
falling, so we said, “Get out of way,” and we all hopped out of the way. And Adriaan
didn’t move so I pushed – I pulled him towards me just to the right side of us.
And it – the tree fell and hit Adriaan on the side of the head, coming down, and
then he sort of fell on the ground …”[77]
“… we were all under [the tree] at one point, and I think EM and OP hopped out to
the left and I hopped out to the right with Rob, and that’s where I pulled Adriaan
from … so we were facing down the mountain and the tree was here, and so we
all hopped under it, and we all had our hands above our head, the same as before.
I think maybe Adriaan was in in the middle. I was at the back … [SC was in front
of me] and then I moved to the middle … as I couldn’t reach it any more I moved
in front of SC [and Adriaan was in front of me] …”[78]
[77] Exhibit A.6 (AFP brief), TROC TC, p56 at A100
[78] Exhibit A.6 (AFP brief), TROC TC, p57 at A105-1151. SC told Police:
“So we all just jumped on and decided to try and lift up and flip over this branch
that was pretty big. Um, and then we got it – I don’t know, pretty high. Like almost standing straight. And then we couldn’t move it any higher. And then it just – we all
just said, “Move out of the way,” And then everyone jumped out of the way and I
think TC tried to push Adriaan out of the way but he didn’t get – move fast enough
and it just – the branch fell on his head and knocked him out.” [79]
[79] Exhibit A.13 (AFP brief), TROC SC (Part 1), p255 at A1952. EM’s handwritten account records:
“the other guys felt confident that they would be able to flip it if the other guys joined
(maybe excluding one) and began to lift it the log…. this wasn't working ….I heard
the guys grunting and …. people moving away …. jumped out of the way ….
dropped the log as I did just split seconds later I looked back and then saw Adriaan
there by himself …” [80]
[80] Exhibit A.32 (AFP brief), TROC EM contemporaneous (1.5-2 hours later) handwritten statement at
53. Adriaan fell sideways toward the ground as the log continued to fall to the ground. In
the process it struck Adriaan again across his head. SC told Police:
“And then [Adriaan] fell under the tree and it crushed his head or, like, bounced off
his head. And we all thought he was just unconscious …” [81]
[81] Exhibit A.13 (AFP brief), TROC SC (Part 1), p255 at A19
54. EM’s handwritten account records:
“… the log landed on Adriaan I don't know if he slipped or wasn't fully aware …”[82]
[82] Exhibit A.32 (AFP brief), TROC EM contemporaneous (1.5-2 hours later) handwritten statement at
55. After being struck by the log Adriaan had blood coming from his ears, nose and mouth;
his eyes were closed, he made no sound and he was not moving. SC told Police:
“… we all thought [Adriaan] he was just unconscious … the blood just started
spraying out of his nose … and then I held Adriaan’s nose, um, to stop the bleeding
and put him in the recovery position. And then opened his mouth to let him breathe
and he – and then the blood just started pouring – like, flowing – pretty much started
flowing out of this mouth … and then it started coming out of his ears as well. Out
of the top – the ear that was facing up. And it was just flowing out.” [83]
[83] Exhibit A.13 (AFP brief), TROC SC (Part 1), p255 at A1956. Another student LP (14 years old) arrived at the incident scene shortly after the incident.
He was about 15 to 20 metres away from the ‘gaol’ and observed the boys lifting a log
but didn’t take much notice.[84] LP told Police:
“… I heard it fall. I didn’t actually see it fall. I heard it crash and then crack on the
ground. And then, um, oh, the – the guys up there were like, “Someone get a
teacher.” I think one of them said, “His mouth’s foaming”, but I’m not confident with
that. And, ah, um, so at this point, I’ve gotten up and I’m walking up to see what’s
happened, And then I see, ah, Adriaan on the ground – this is the kid who got hit.
He got – he’d been whacked on the head apparently. And um, ah, he’s just been
knocked out completely. Blood was coming out of his ears, nose and mouth.” 85
[84] Exhibit A.5 (AFP brief), TROC LP, p40 generally 85 Exhibit A.5 (AFP brief), TROC LP, p42 at A15-17
57. EM’s handwritten account recorded:
“… I then saw blood and started sprinting instantly to get the teacher. Educator 3
began sprinting to the guys and Adriaan … SC is calling an ambulance...” [86]
[86] Exhibit A.32 (AFP brief), TROC EM contemporaneous (1.5-2 hours later) handwritten statement at
58. Immediately appreciating the seriousness of the incident, SC asked another student to
call the ambulance and took over the call from her.[87] SC put the telephone on
loudspeaker before transferring the call to Educator 1 when teachers arrived at the
incident scene.[88]
[87] Exhibit A.13 (AFP brief), TROC SC (Part 1), p255 at A19
[88] Exhibit A.33 (AFP brief), 000 call transcript, p487-488
59. From the 000 call it appears that contact was made with first responders at 10:50:40
am.[89] Teachers were likely to have been at Adriaan’s side within 90 seconds, probably
at 10:52:28 and definitely by 10:53:57, although this is not able to be determined with
absolute precision.[90]
[89] Exhibit A.33 (AFP brief), 000 call transcript, p485-492
[90] The talking in the background on the recording is indistinct. However:
60. TC told Police that he ran to teachers to seek help from Educator 4, Educator 3 and
Educator 1 who he stated were “about fifteen metres”[91] away at that time. He said it
took him ‘not even fifteen seconds’ to reach the teachers.[92]
[91] Exhibit A.6 (AFP brief), TROC TC, p50-1 at A23-27
[92] Exhibit A.6 (AFP brief), TROC TC, p61 at A16561. LP told Police:
“I saw SC, who was there, holding [Adriaan’s] nose and calling the ambulance. Ah,
then not too long after that – almost immediately – ah, the teachers –Educator 3 runs up and, ah, checks out – checks out Adriaan, grabs his nose … so that Rob
can continue talking to the, ah, you know, medical staff.” [93]
[93] Exhibit A.5 (AFP brief), TROC LP, p42 at A17-1962. Educator 3 told Police that EM came running towards him to advise him of Adriaan’s
injury.[94] He said that when running up the hill to where Adriaan was, he could not see
[94] Exhibit A.12 (AFP brief), TROC Educator 3, p222 at A16
Adriaan, because Adriaan and the other students were behind some low bushes that
came up to about waist height.[95]Educator 3 said:
[95] Exhibit A.12 (AFP brief), TROC Educator 3, p236 at A158 & p238 at A171-2
“I actually sprinted up the hill to where they were, which was about, oh, fifty metres
or so away, um, but its, because its bushland, you can’t exactly see what’s
happening all the time … I ran up there, blood, ah – Adriaan was lying on his back,
with blood coming out his ears, nose, ah, and mouth. Ah, wasn’t looking well at all.
He was unconscious, um, because I called for his name, ah, just to see if there
was any response. … a lot of blood was just literally running out his nose like a tap.
Um, so I pinched his nose to try and stop that. Um, realised that he had a heap of
blood in his mouth, so I turned him over to his side,[96] ah, while pinching his nose,
to make sure I could have the blood running out of his mouth, um, and his nose at
that stage, and hopefully his lower ear.”[97]
[96] This action appear to occur by at least 10:53:27 and is possibly 10:52:28, having regard to the 000
[97] Exhibit A.12 (AFP brief), TROC Educator 3, p222 at A16
63. Educator 1 told Police that after being told of the incident he and Educator 3 ran up as
quick as they could get to Adriaan.[98] He described the distance involved as roughly
‘twenty paces, it wasn’t that far’.[99] Educator 1 said:
“… I’ve looked down and I’ve seen Adriaan with his arm stuck underneath the log that
he’d – the kid said he’d lifted up. Um and then I’ve looked down and I saw blood
coming out of his ears, blood coming – a – a gush behind both of his ears. Um, blood
coming out of his – his mouth and his nose as well. Like, profusely. Um, a really – a
– a – a large amount of blood. Um really alarmingly amount. So the – the boy was on
the phone to the – the ambulance at that point…”[100]
[98] Exhibit A.7 (AFP brief), TROC Educator 1, p70 at A14
[99] Exhibit A.7 (AFP brief), TROC Educator 1, p74 at A56-8
[100] Exhibit A.7 (AFP brief), TROC Educator 1, p74 at A52-3
64. Educator 1 and Educator 3 lifted and moved the log off Adriaan. Educator 1 said it
required them both to lift it[101] and described the process as follows:
“… it was quite a heavy log… we were under quite a bit of strain to move that log…”102
[101] Exhibit A.7 (AFP brief), TROC Educator 1, p76 at A85-86 102 Exhibit A.7 (AFP brief), TROC Educator 1, p74 at A63-64
65. It was unclear to Educator 1 and Educator 3 whether Adriaan was breathing.[103]
[103] Exhibit A.7 (AFP brief), TROC Educator 1, p71 at A17, p76-77 at A91-94; Exhibit A.12 (AFP brief),
66. LP, TC, OP and EM all went down the hill to the road to meet emergency services,[104]
while Educator 2 and Educator 5 began collecting the remaining students in the field and
returning them to the school.[105]
[104] Exhibit A.5 (AFP brief), TROC LP, p34 at A20
[105] Exhibit A.12 (AFP brief), TROC Educator 3, p250-1 at A310-4
67. Shortly after Educator 3’s arrival at Adriaan’s side.[106] BC, a Registered Nurse, was
walking along the walking trail. She observed a number of students running to the
incident location and decided to attend to see if she could lend assistance. BC observed
Adriaan laying on his left side with a large amount of blood coming from his head. BC
checked his pulse, which she described as a ‘good radial pulse’. She observed Adriaan’s
skin started to change colour and realised he was no longer breathing.[107]
[106] Exhibit A.12 (AFP brief), TROC Educator 3, p222 at A16 – he says:
[107] Exhibit A.34 (AFP brief), Statement of BC, p505-508
68. Educator 1 took the phone from SC and started talking to the ACT Ambulance Service
(“ACTAS”) dispatcher.[108] The dispatcher gave advice over the phone to commence
cardiopulmonary resuscitation (“CPR”).[109]
[108] Exhibit A.7 (AFP brief), TROC Educator 1, p77 at A95-98
[109] Exhibit A.33 (AFP brief), 000 call transcript, p487-488
69. Educator 3 began doing chest compressions on Adriaan while BC assisted by removing
blood from Adriaan’s mouth to keep his airway clear while waiting for ACTAS to arrive.[110]
[110] Exhibit A.12 (AFP brief), TROC Educator 3, p223 at A16, Exhibit A.34 (AFP brief), Statement of BC,
First Responders
70. About 10 to 15 minutes after the incident, at 10:59am, ACTAS paramedics arrived at
Mount Ainslie.[111] They were escorted by teachers and students up to the incident
location.[112]
[111] Exhibit A.34 (AFP brief), ACTAS Incident Log, p503-4
[112] Exhibit A.36 (AFP brief), Statement of Daniel Keyte, p50971. The paramedics attended the scene and took over First Aid from Educator 3. ACT Fire
and Rescue (“ACTFR”) also arrived and assisted ACTAS in conducting chest
compressions.[113]
[113] Exhibit A.36 (AFP brief), Statement of Daniel Keyte, p510 generally72. About 15 minutes after ACTAS arrival, and after continuous chest compressions and a
shot of adrenaline, Adriaan’s circulation spontaneously returned. ACTAS paramedics
then placed Adriaan onto a stretcher and, with the assistance of ACTFR officers,
conveyed him into the ambulance before departing the location for hospital. [114]
[114] Exhibit A.37 (AFP brief), Statement of Hilary Dingjan, p516-7 generally
73. Adriaan’s heart again stopped beating during that journey to hospital. Compressions
were recommenced and a further adrenaline shot was administered. This treatment had
the effect of returning spontaneous circulation.[115]
[115] Exhibit A.37 (AFP brief), Statement of Hilary Dingjan, p517 generally
Adriaan’s Death
74. ACTAS began transporting Adriaan to The Canberra Hospital (“TCH”) at about 11.31
am. [116] They arrived at about 11:47am. [117]
[116] Exhibit A.34 (AFP brief), ACTAS Incident Log, p503-4
[117] Exhibit A.34 (AFP brief), ACTAS Incident Log, p503-4; see also Exhibit A.24 (AFP brief), Statement
75. On arrival at hospital, Adriaan underwent vascular access intubation and fluid
resuscitation. He was transported for a Computed Tomography (“CT”) scan with ongoing
resuscitation due to gross instability in his circulation.[118]
[118] Exhibit A.24 (AFP brief), Statement of Dr Hall, p359 generally
76. The CT scan showed severe brain and skull injurie, a severe spinal cord injury and a
fractured mandible.[119]
[119] Exhibit A.24 (AFP brief), Statement of Dr Hall, p359 generally
77. A discussion was held amongst Adriaan’s treating doctor. They concluded that there
was no appropriate surgical intervention available and that Adriaan’s injuries were not
survivable. Adriaan’s family were informed of this clinical opinion and made the decision
to provide pain relief and cease life support to Adriaan.[120]
[120] Exhibit A.24 (AFP brief), Statement of Dr Hall, p359 generally
78. At about 2.56pm, with his family present, Adriaan was formally pronounced life extinct in
hospital.[121]
[121] Exhibit A.19 (AFP brief), Statement of Life Extinct, p33979. Dr Hall, the primary ED doctor who treated Adriaan, considered that the cause of
Adriaan’s death was circulatory failure, secondary to traumatic brain injury consistent
with blunt force trauma to the head. [122]
[122] Exhibit A.24 (AFP brief), Statement of Dr Hall, p360 at [13]80. Adriaan did not regain consciousness at any point following the incident.[123]
[123] Exhibit B.2 (WorkSafe brief), Inspector Majer’s summary, p5 at [10]
81. Adriaan’s death was reported to the ACT Coroner in accordance with section 13(1)(k)
of the Coroners Act 1997, as apparently being the result of an accident.[124]
[124] Exhibit A.40 (AFP brief), Police Coronial Report, p531-540
82. At about 5:58pm, Police were advised that the Chief Coroner was satisfied that there
was no need for a post-mortem examination in the circumstances and released
Adriaan’s body to his family. [125]
[125] Exhibit A.2, Statement of F/C James, p6
The Investigation
83. ACT Policing commenced an investigation of the circumstances of Adriaan’s death
on behalf of the Coroner.
84. WorkSafe ACT, in their role as the relevant work health safety regulator, conducted
its own investigation and also assisted with the coronial investigation.
85. Police Forensics officers attended TCH and obtained imagery of Adriaan and the
Resuscitation department where he was treated.[126] Police Forensics attended the
scene at Remembrance Memorial Park where the log was located and photographed,
measured, and weighed it.[127]
[126] Exhibit A (AFP brief):
[127] Exhibit A (AFP brief):
86. As a result of their investigation, Police concluded that there were no suspicious
circumstances in Adriaan’s death.[128]
[128] Exhibit A.2, Statement of F/C James, p2
87. After being provided with the evidence obtained during the WorkSafe ACT
investigation, on 9 October 2020, the Office of the Director of Public Prosecutions
(ACT) formally advised WorkSafe ACT they would not be instituting proceedings in
this matter due to insufficient prospects of conviction.[129]
[129] Exhibit B.2 (WorkSafe brief), Volume 1, Item 2, Inspector Majer’s summary, p21 at [109]
88. Thereafter, briefs of evidence was submitted to the Coroner. Additional material was
also submitted on behalf of the Roodt family.
The Aftermath
89. Since Adriaan's tragic death the activity ‘Capture The Flag’ is no longer played on the
Mount Ainslie site. Since the incident no other games or activities of this nature are
undertaken by Campbell High School on Mount Ainslie in the area which ‘Capture
The Flag’ was played on 18 October 2018. All invasion fitness games such as
‘Capture The Flag’ are now played on the school grounds in areas such as the oval,
gym or outdoor courts.[130]
[130] Exhibit D.1, Statement of Educator 8, p1-2
Relevant Directorate Policies and Procedures in place in 2018
90. The ACT Education Directorate Physical Education and Sport Policy[131] defined ‘sport’
as:
‘The collective term for all physical activity formalised by a set of rules, usually
competition based. In a school environment, sport can occur within the physical
education curriculum and as an extracurricular activity.’
[131] Exhibit B.21 (WorkSafe brief), p2093-2096
91. The Physical Education and Sport Procedures[132] defined ‘a physical activity’ as ‘being
all movements in everyday life which accelerates the heart rate’.
[132] Exhibit B.22 (WorkSafe brief), p2097-2104
92. The Excursions Policy[133] defined an ‘excursion’ as:
‘a school related activity by students, under the supervision of a teacher/s, directly
related to the curriculum of the school. An excursion is a variation to normal activity
and is not predominately recreational.’
[133] Exhibit B.19 (WorkSafe brief), p2083-2085
93. There were four types of categories of excursions defined in the Excursions
Procedures.[134] Category A excursions are described as ‘movement, generally on foot
or by bicycle in the vicinity of the school or a variation to normal activity’. The minimum
supervision ratio is one teacher per class group.
[134] Exhibit B.20 (WorkSafe brief), p2086-2092 135 Exhibit B.25 (WorkSafe brief), p2118-2223
94. Part 3.1 of the Physical Education and Sports Procedures stated:
‘A comprehensive list of physical education activities and sports activities approved
for ACT public schools is provided in the ‘Physical Education and Sport: Activity-
Specific Mandatory Guidelines’.
95. The Physical Education and Sport: Activity-Specific Mandatory Guidelines135 did not
list ‘Capture The Flag’ as an approved activity.
96. Part 3.3 of the Physical Education and Sports Procedures stated:
‘Additional procedures and revisions are issued from time to time, either on request
or because new activities are recognised. Schools will be advised of changes through
appropriate communication channels. The Directorate’s Learning and Teaching
Branch will consult with Governance and Community Liaison Branch prior to granting
approval.’
97. Section 2.8 of the Physical Education and Sports Policy stated:
‘Teachers planning to conduct any activities not listed as approved physical education
or sport activities must submit a proposal to the Learning and Teaching Branch for
consideration to be included as an approved activity. The Directorate will notify
schools of additional approved activities.’
98. Prior to this incident, the game of ‘Capture The Flag’ had not been formally approved
or recognised by the Directorate as a physical activity.[136]
[136] Exhibit B.2 (WorkSafe brief), Inspector Majer’s summary, p7 at [15]99. The Physical Education and Sport: Activity-Specific Mandatory Guidelines included a
category of activity described as “minor games”. The introduction to that section of
the guidelines stated:
‘All activities and personnel must be approved by the principal.
Minor games are frequently used to reinforce basic skills and lead-up games to major sports. Care is needed in the conduct of such games and teachers should be familiar with the safety requirements of the major game for which the lead-up game is designed.
Where a minor game is used as a lead up to or replacement for the full game, teachers must follow safety guidelines which remain applicable to the game in its
modified form.’
100. Prior to this incident, there was no specific list of minor games approved by the principal of Campbell High School.
101. Section 5(1) of the Physical Education and Sports Policy stated:
The principal is responsible for a number of things including:
(a)
Verifying appropriate safety measures are in place in accordance with risk assessment and management plans.
(b) Ensuring all the physical education and sport activities meet the requirements of relevant Directorate policies.’
102. Part 3.4 of the Physical Education and Sports Procedures stated:
‘The principal is responsible for a number of things including;
(a) ensure that all teachers delivering physical education activities and sporting
events are aware of their responsibilities.
(b) ensure where appropriate Risk Assessment and Management Plan is
completed for physical education activities and sporting events.
(c) ensure the planning and delivery of all physical education and sporting events
meet the requirements of relevant Directorate policies and procedures.’
103. Part 3.5 of the Physical Education and Sports Procedures stated:
‘Teachers delivering physical education and sporting activities will:
(a) be familiar with the Physical Education and Sports Policy, Physical Education
and Sport: Activity-Specific Mandatory Guidelines and implement all requirements
for individual sports.’
104. Part 3.23 of the Physical Education and Sports Procedures stated:
‘Part of the planning process for each physical education activity and sporting event
is the requirement to complete a Risk Assessment and Management Plan. This is
a careful examination of what could cause harm to participants during the course of
the activity and a plan of practical risk control measures that the teacher in charge
of the physical activity and sporting event will put in place to minimise (to an
acceptable level) the risk of harm occurring.’
105. Part 3.24 of the Physical Education and Sports Procedures stated:
Physical education sport or activities conducted on the school site as part of the core
physical education curriculum do not require a risk assessment or management
plan. Inclusive strategies for maximising student participation and safe guarding
student safety and wellbeing must be evident in the curriculum program.’
106. Part 3.25 of the Physical Education and Sports Procedures stated:
‘All physical education or sport activities/events conducted off the school site (e.g.
athletics or cross-country events) require a Risk Assessment and Management Plan
and adherence to the Physical Education and Sport: Activity-Specific Mandatory
Guidelines.’
107. There was no specific risk assessment or planning documentation created or
otherwise in existence at Campbell High School relating to the ‘Capture The Flag’
game for 18 October 2018.
108. There were no risk assessment or planning documentation created or otherwise in
existence at Campbell High School relating to the ‘Capture The Flag’ game at
Campbell High School generally (irrespective of playing location) prior to this
incident.
109. There were no risk assessment or planning documentation created or otherwise in
existence at Campbell High School relating to school activities occurring at
Remembrance Memorial Park prior to this incident
110. The game of ‘Capture The Flag’ had not been formally approved or recognised by
the principal of Campbell High School as an approved physical activity prior to this
incident. There was an undated list of games played at Campbell High School from
an unknown author in which ‘Capture The Flag’ was mentioned as being played on
Reid Oval, with no mention of any activity being played on Mount Ainslie.[137]
[137] Exhibit B.2 (WorkSafe brief), Inspector Majer’s summary, p18 at [103]
C. A FEW COMMENTS ON WHAT FOLLOWS 111. It is important for the parties to know that I have read all of their counsel’s
submissions and submissions in reply on the issues. I have agreed and disagreed
with counsel’s very helpful submissions at various points. This does not mean that
I have disregarded any submission or not given it full weight – I have indeed done
so. I thank counsel for their depth of analysis of the materials and great level of detail
that is evident in their submissions. Those submissions have been of great
assistance to my consideration and re-consideration of this matter.
112. I have highlighted comments, findings and recommendations in bold text along the
way from this point on and made some further ones at the end of the document.
D. ISSUES 113. The following issues for consideration were developed by counsel assisting,
provided to the parties, and approved by me. They represent what I understand to
be an agreed distillation of the issues that are central to my findings under s 52 of
the Coroners Act 1997:
1. Whether the game of ‘Capture The Flag’, specifically when conducted at
Remembrance Memorial Park in 2018, was to be properly characterised
(within the meaning of these terms in ACT Education Directorate policies and
procedures) as: a. Taking place on the school site; b. Taking place off the
school site; c. Physical activity; d. Sport activity; e. A classroom activity; f. A
recreational activity; g. A physical education activity; h. An excursion; i. A minor game; j. An outdoor education activity; or k. Some combination of the
above.
2. Whether the game of ‘Capture The Flag’ conducted at Remembrance
Memorial Park on the day of the incident was conducted in accordance with
the relevant guidance material (including policies and procedures) in force at
that time.
3. The appropriateness of that guidance material.
4. Whether there was appropriate supervision of the game on that day in all the
circumstances of the incident.
5. Whether there was appropriate training and guidance given to the teachers
who conducted the game on that day.
6. Potential recommendations in relation to matters of public safety or other
matters.
7. Any other relevant issue that arises during the course of the inquest.
What was the activity
The ACT Education Directorate (“the Directorate”) has many documented policies and
procedures that relate to physical education and off school activities. Campbell High
School also has its own internal documentation about physical education (“PE”) and off-
school activities. In 2018 these policies and procedures were tiered depending on the
specific nature of the activity in question, with different requirements depending upon the
activity’s location, character, inherent risk, and other relevant factors.
115. It became clear during the WorkSafe ACT investigation that there were differing opinions
held by Campbell High School teachers as to how the game of ‘Capture The Flag’,
specifically when conducted at Remembrance Memorial Park in 2018, was to be properly
characterised. Even after looking at the policies and procedures, some teachers
remained unsure of the correct categorisation.
116. At the time of this incident Educator 4 was a teacher and a senior staff member at the
school.[138] He described ‘Capture The Flag’ as a fitness activity that was very popular
[138] Exhibit B.26 (WorkSafe brief), TROC Educator 4, p2227 L21-33
and one that the children loved playing.[139] Educator 4 repeatedly characterised ‘Capture
[139] Exhibit B.26 (WorkSafe brief), TROC Educator 4, p2232 L19-20
The Flag’ as ‘a normal classroom activity’[140] but acknowledged difficulty in how to
[140] Exhibit B.26 (WorkSafe brief), TROC Educator 4, p2254 L26-27, p2258 L19-21, p2259 L10-13, p2260
properly characterise the activity as a class activity, an approved class activity or an
outdoor education activity.[141] He acknowledged that ‘Capture The Flag’ could also be
[141] Exhibit B.26 (WorkSafe brief), TROC Educator 4, p2256 L14-23
classified as an excursion[142] and also an outdoor adventure activity[143] under the
[142] Exhibit B.26 (WorkSafe brief), TROC Educator 4, p2261 L12-25
[143] Exhibit B.26 (WorkSafe brief), TROC Educator 4, p2264 L36-2265 L41
Directorate’s policies.
117. Educator 7 was in a senior position at Campbell High School. Prior to taking up that
position Educator 7 was a senior teacher at the school.[144]. Educator 7 claimed in PE it
[144] Exhibit B.28 (WorkSafe brief), TROC Educator 7, p2331 L8-18
was a strongly held belief that ‘Capture The Flag’ was probably the most popular activity
they conducted and it received the highest levels of engagement of students engaging
in the fitness lessons of any sport or fitness activity. The PE faculty saw it as being a very
positive and beneficial activity.[145] She felt ‘Capture The Flag’ may have been a
[145] Exhibit B.28 (WorkSafe brief), TROC Educator 7, p2338 L31-35
classroom activity,[146] or a modified game as detailed in the mandatory PE policy.[147]
[146] Exhibit B.28 (WorkSafe brief), TROC Educator 7, p2340 L31-32
[147] Exhibit B.28 (WorkSafe brief), TROC Educator 7, p2341 L3-5
When asked if the game on Mount Ainslie fitted in to the Excursion Policy Educator 7
stated that before the incident she did not believe so; since the incident they had looked
at in the policies but believed it was still a grey area.[148] She stated that she did not think
[148] Exhibit B.28 (WorkSafe brief), TROC Educator 7, p2344 L1-9
it was an excursion because there was an understanding that excursions to areas
immediately adjacent to the school do not require specific excursion proposals every
time and that they are included in the general consent that parents give for their children
at the start of the year.[149] Educator 7 agreed that ‘Capture The Flag’ was a sporting
[149] Exhibit B.28 (WorkSafe brief), TROC Educator 7, p2344 L28-p2345 L16
physical activity and that it would need to be an approved activity.[150] She stated it would
[150] Exhibit B.28 (WorkSafe brief), TROC Educator 7, p2349 L15-32
have been in the PE and Sport Activity-Specific Mandatory Guidelines, but
acknowledged when shown the relevant document that it was not included.[151]
[151] Exhibit B.28 (WorkSafe brief), TROC Educator 7, p2349 L25-39
118. Educator 1 was a teacher at Campbell High School.[152] He was of the opinion the game
[152] Exhibit B.27 (WorkSafe brief), TROC Educator 1, p2286 L39-42
was an approved game within the Directorate,[153] and would have been approved by the
[153] Exhibit B.27 (WorkSafe brief), TROC Educator 1, p2294 L27-31
principal.[154] Educator 1 said that he considered ‘Capture The Flag’ was a normal
[154] Exhibit B.27 (WorkSafe brief), TROC Educator 1, p2301 L6-9
classroom activity but acknowledged that it also fitted into the excursion classification.[155] He said that when conducted on Mount Ainslie it was an excursion and when conducted
[155] Exhibit B.27 (WorkSafe brief), TROC Educator 1, p2306 L3-16 &13-22on the oval it was within the sport and physical activity area.[156]
[156] Exhibit B.27 (WorkSafe brief), TROC Educator 1, p2317 L40-42
119. Educator 8 held a senior position at Campbell High School.[157] He had been acting in the
[157] Exhibit B.29 (WorkSafe brief), TROC Educator 8, p2369 L25-39
position for the 10 weeks prior.[158] Educator 8 was aware of ‘Capture The Flag’ and was
[158] Exhibit B.29 (WorkSafe brief), TROC Educator 8, p2370 L8-14
aware it had been played on Mount Ainslie for some time, although he was unaware that
it was being played on the day of the incident.[159] He had played it before in 2006 and
[159] Exhibit B.29 (WorkSafe brief), TROC Educator 8, p2375 L35-41
believed it to be a physical education activity.[160] Educator 8 was unaware if the game
[160] Exhibit B.29 (WorkSafe brief), TROC Educator 8, p2375 L35-p2376 L2
had been formally recognised by the Directorate.[161] He was unaware of the possible
[161] Exhibit B.29 (WorkSafe brief), TROC Educator 8, p2378 L19-22
application of the Excursions Policy to the game.[162]
[162] Exhibit B.29 (WorkSafe brief), TROC Educator 8, p2380 generally
120. Educator 9 was a senior staff member of Campbell High School and had previously
occupied the same position as Educator 8.[163] She stated ‘Capture The Flag’ was played
[163] Exhibit B.30 (WorkSafe brief), TROC Educator 9, p2398 L21
at Campbell High School on Mount Ainslie and agreed it was part of PE curriculum.[164]
[164] Exhibit B.30 (WorkSafe brief), TROC Educator 9, p2410 L23-37
She stated Mount Ainslie, the War Memorial and Reid Oval have, as a matter of culture,
been considered an extension of the school grounds for many years.[165] She added that
[165] Exhibit B.30 (WorkSafe brief), TROC Educator 9, p2411 L23-29 & p2413 L3-16
parents gave their consent for children to use those particular learning spaces when they
start at the school.[166] She assumed ‘Capture The Flag’ was an approved activity
[166] Exhibit B.30 (WorkSafe brief), TROC Educator 9, p2413 L40-p2414 L3
because it was played in a lot of schools.[167]
[167] Exhibit B.30 (WorkSafe brief), TROC Educator 9, p2414 L14-20
121. In response to a Section 155 Notice issued by WorkSafe ACT under the Work Health
and Safety Act 2011, the Directorate stated that ‘Capture The Flag’ was a minor game,
that the lower slopes of Mount Ainslie were part of the Campbell High School site and
accordingly, a risk assessment plan was not required for this PE class.
I find that the relocation of the game to Remembrance Memorial Park both changed
the nature of the game and how it was to be played. Accordingly, different
guidance material and requirements beyond those for mere classroom activities
were applicable.
The classification by some teachers as ‘a classroom activity’ appears tied up in the fact
that parents of students at Campbell High School gave enduring consent for certain supervised activities approved by the principal to take place off school grounds and
therefore no specific, additional excursion permission was required.[168] The close vicinity
[168] Exhibit B.30 (WorkSafe brief), TROC Educator 9, p2413 L40-p2414 L3of Mount Ainslie to the school grounds seems also to have been a relevant factor in this
classification.[169] However, this does not denigrate from the fact that leaving the school
[169] Exhibit B.27 (WorkSafe brief), TROC Educator 1, p2311 L9-10; Exhibit B.30 (WorkSafe brief), TROC
grounds always constituted an excursion and fell under the Excursions Procedures,
given particularly the definition of Category A excursions as “‘movement generally on
foot or by bicycle in the vicinity of the school or a variation to your normal activity’.[170]
[170] Exhibit B.20 (WorkSafe Brief), ACT Education Directorate Excursion Procedures, p2088 at [3.4]
124. The parental consent on file at Campbell High School for Adriaan was dated 18 February
2016. The form of that consent was in terms of activities approved by the principal, and
the evidence discussed below suggests that at no time was ‘Capture The Flag’ officially
approved by a principal of Campbell High School.
I find that the game of ‘Capture The Flag’, specifically when conducted at
Remembrance Memorial Park in 2018, was very obviously a physical education
activity and it was not conducted on the school site. It could also have been
characterised under Directorate policies and procedures in force at the relevant
time as each of:
(a) Taking place off the school site;
(b) A physical activity;
(c) A sport activity;
(d) A recreational activity;
(e) A physical education activity;
(f) An excursion;
(g) A minor game; and
(h) An outdoor adventure activity.
What was the relevant Guidance Material, and was it complied with
As ‘Capture The Flag’ could be characterised under Directorate policies and procedures
as multiple types of activities, it follows that there were an amalgamation of multiple and
differing requirements:
(a) For a physical activity, there was a general requirement that the school principal
should develop a risk assessment and management plan;171
(b) As it took place off, but close, to the school site, the activity could be considered a Category A excursion. In those circumstances the venue had to be approved
by the principal;[172]
[172] Exhibit B.22, ACT Education Directorate Physical Education and Sport Procedures, p2100 at [3.19]
(c) If predominantly a recreational activity, the Excursions Policy did not apply;[173] (d) For a Category A excursion, the completion of a risk assessment proforma was [173] Exhibit B.19 (WorkSafe Brief), ACT Education Directorate Excursion Policy, p2084 at [10.1]
recommended but not mandatory.[174] Notification of a category A excursion
[174] Exhibit B.20 (WorkSafe Brief), ACT Education Directorate Excursion Procedures, p2087 at [3.1]
must have been sent to parents;[175]
[175] Exhibit B.20 (WorkSafe Brief), ACT Education Directorate Excursion Procedures, p2089 at [3.7]
(e) For a physical education or sport activity conducted off the school site, a risk assessment and management plan was required to be completed.[176] Informed
[176] Exhibit B.22, ACT Education Directorate Physical Education and Sport Procedures, p2101 at [3.23]-
consent and current medical information was required from each student’s
parents, unless exempted in the Excursion Procedures;[177]
[177] Exhibit B.21, ACT Education Directorate Physical Education and Sport Policy, p2093 at [2.7]
(f) If the activity was not a formally approved activity, a proposal for its approval must have been submitted to the Directorate for consideration to be included
as an approved activity;[178]
[178] Exhibit B.21, ACT Education Directorate Physical Education and Sport Policy, p2093 at [2.8] & Exhibit
(g) If a minor game was being conducted in the school’s immediate environs, a risk assessment was not required, but the activity must have been approved
by the principal;[179] and
[179] Exhibit B.25, ACT Education Directorate Physical Education and Sport Activity-Specific Mandatory
(h) For an outdoor adventure activity a risk assessment is mandatory.[180]
[180] Exhibit B.24, ACT Education Directorate Outdoor Adventure Activities Procedures, p2113 at [3.27]-
127. A former Campbell High School teacher, Educator 6, was asked by investigators to work
out where ‘Capture The Flag’ when played on Mount Ainslie fitted in relation to the
policies. He replied “I would need to be given substantial time off work to make that
happen…it’s not an easy task”.[181]
[181] Exhibit B.30 (WorkSafe brief), TROC Educator 6, p2672 L8-36
128. The expert report of Dr Dallat and Professor Salmon (Dallat/Salmon) confirms that any
of the relevant policies could relate to the ‘Capture The Flag’ activity.[182]
[182] Exhibit E.1, p17 at [8]-10]
129. An expert report by John Leyshon (Leyshon), a retired teacher and acting principal of
some 40 years’ experience including in the ACT, includes an opinion[183] that paragraph
[183] Exhibit E.2, p28
3.25 of the Physical Education and Sports Procedures applied as the location of the
activity was not on the school grounds and mandated a risk assessment and
management plan.184
It was submitted that it was a grey area[185] as to whether a risk assessment and
[185] Exhibit B.28 (WorkSafe brief), TROC Educator 7, p2344 L7
management plan was formally required to be undertaken under the relevant
policies and guidelines in place at the time. However, I find that a risk assessment
and management plan should have been completed as the activity was very
obviously a physical education activity and it was not conducted on the school
site.
As Mr Leyshon said “even without the directions of the procedures document an
experienced teacher should have intuitively prepared a risk assessment for this type of
activity on this site”.[186]
[186] Exhibit E.2, p28
132. My finding is fortified by the evidence given by Educator 1 to investigators when asked
about risk assessments:
“I do remember about four or five years ago [Educator 6] said, "I want risk
assessments for all activities that we do offsite," I wasn't a part of that because I
wasn't in that faculty at that time but I do vaguely remember that PE staff were going
to go through the process of writing those but then he left the school and moved to
a new school before that process maybe was carried out if that makes sense. I
haven't actually looked to see if there is a risk assessment.”[187]
[187] Exhibit B.27 (WorkSafe brief), TROC Educator 1, p2300 L39-45
133. Dallat/Salmon say that this specific incident could reasonably have been foreseen, but
that complacency and long-term delivery of ‘Capture The Flag’ without serious incident
or injury made it very unlikely that the incident was foreseeable by the staff. They suggest challenging boundaries and actions, such as attempting to move logs, are
reasonably foreseeable where young people are placed in ‘gaol’ for an extended period
of time without adult supervision.[188]
[188] Exhibit E.1, p18-19 at {18]-[22]
134. Leyshon qualified his opinion on this point, saying that the specific instance of a very
heavy tree branch being lifted into an upright position may not have been foreseen “even
by the best risk assessment”, but that it was reasonable to predict that adolescent boys
may engage in mischief and misbehaviour, particularly if left bored and unattended, or in
small groups.[189]
[189] Exhibit E.2, p28
135. There were in existence at Campbell High School risk assessment and management
plans for “Bushwalking, Hiking and Orienteering” (for Morton National Park, Namadgi
National Park and Canberra Nature Park)[190] and for the 2017 cross-country carnival
[190] Exhibit A.28, p373-386
which was held at the base of Mount Ainslie.[191] In the latter document completed for the
[191] Exhibit A.29, p387-392cross-country carnival, there were 20 supervising staff designated for 400 students (a
ratio of 1:20).
136. A number of risks were identified including medical emergency through non-incident (i.e.
severe chest pains, asthma attack), medical emergency through incident (i.e. slip and
fall, penetrating wounds, hit by vehicle), separation from group, unacceptable student
behaviour, walking to/from venue (hit by vehicle) and incident/injury. For “unacceptable
student behaviour”, the likelihood of this occurring was assessed as “possible” and the
consequence was assessed as “moderate”; the stated control measure used to address
this risk was to brief the students on expectations prior to the departure to the cross-
country carnival.
I find that the risk of injury to a student from the natural environment at
Remembrance Memorial Park while playing ‘Capture The Flag’ was not known to
staff at Campbell High as they had not been provided with or conducted a risk
assessment and management plan. The risk assessments that had been
completed were cursory and unwritten and failed to properly assess and
appreciate all foreseeable risks including the risk of mischief and misbehaviour
associated with bored teenage boys.
138. When shown by investigators a number of the policies and procedures including the PE
and Sport Policy, the PE and Sport Procedures and the Outdoor Adventure Activities
Policy, and asked if they had any relationship to ‘Capture The Flag’, Educator 8 replied:
“I don't think they - I can confidently say they haven't been used in relation to Capture
The Flag.” [192]
[192] Exhibit B.29 (WorkSafe brief), TROC Educator 8, p2381 L41-42
139. Educator 8 said he was not asked to approve Mount Ainslie as a venue for ‘Capture The
Flag’, or the game itself.[193]
[193] Exhibit B.29 (WorkSafe brief), TROC Educator 8, p2386 L9-12
140. Educator 9 did not think a risk assessment for ‘Capture The Flag’ existed but knew the
PE staff would have carried out a briefing with the students and undertaken a dynamic
risk assessment which is part of their work which they have to do for every activity.[194]
[194] Exhibit B.30 (WorkSafe brief), TROC Educator 9, p2418 L41-p2419 L4
She stated:
“… there’s a really strong application of professional judgement that happens there,
but I have not ever really thought that it would have fallen into requiring a risk
assessment. But I can see now of course that we would like to have one.” [195]
[195] Exhibit B.30 (WorkSafe brief), TROC Educator 9, p2419 L8-11
141. Educator 1 said that he did not personally foresee that a risk assessment was needed
for ‘Capture The Flag’.[196] He also told investigators that after the incident he offered to
[196] Exhibit B.27 (WorkSafe brief), TROC Educator 1, p2306 L36-37
draw up a risk assessment for ‘Capture The Flag’ but was directed not to prepare one.[197]
[197] Exhibit B.27 (WorkSafe brief), TROC Educator 1, p2320 L9-26
142. The uncertain nature of how the game was defined created an almost impossible maze
of policy for the teachers to navigate. There was no approval in place for Capture The
Flag at school principal or Directorate level. One of the reasons for that is that an
assessment of the proper categorisation for the activity had never been conducted
despite the many years that the activity had been conducted over
143. Whilst the game can be most easily categorised as a physical education activity
conducted off site, that does not mean that it was not also properly categorised as an
excursion. The fact that an assessment of categorisation had not been conducted does
not mean that the requirements of multiple categories of activity did not require
compliance. It also does not void a basic requirement for the Directorate and principals
to approve school-led activities at their schools.
I find that the requirements dictated by the Directorate and applicable to the game
of ‘Capture The Flag’ played on 18 October 2018, were not complied with in relation
to this incident. This is in regard both to the lack of a risk assessment and
management plan and the fact that Adriaan’s parents were not notified of the
intended game. Further, and regardless of how the policies at the time might have
been interpreted one possible way or another, the game was an activity conducted
by the school that was not approved by the school principal or the Directorate at
all.
Was (and is) the guidance material appropriate
The Dallat/Salmon report opines that neither the ‘Capture The Flag’ activity per se, nor
the environment at Remembrance Memorial Park where it was played in 2018, was
unsuitable for the age group and previous experience of the students present on 18
October, but qualify their statement with the proviso “with appropriate risk assessment,
supervision and structure”.[198]
[198] Exhibit E.1 p15 at [1]
146. Leyshon disagreed with this assessment, saying that in addition to the supervision
aspect (discussed below) the site at Remembrance Memorial Park was always
unsuitable, because of environmental damage and the risks to personal safety posed to
students on the site was far too great.[199]
[199] Exhibit E.2 p28-29. Leyshon comments further that he finds the reports of no serious injuries from
147. I prefer the conclusion and reasoning of Dallat/Salmon, that the activity might well have
been appropriately and safely conducted at Remembrance Memorial Park under
different game rules and arrangements (particularly in relation to levels of supervision
and supervision ratios).
148. The Territory has submitted that my comment in the next paragraph about the
inadequacy of the guidance material is “not warranted by the evidence”.[200] The evidence
[200] Submissions by the Australian Capital Territory in response to s55 notice, provided to the Court on
speaks for itself and I reject that submission.
The fact that ‘Capture The Flag’ as an activity was so difficult to categorise and
was capable of falling into multiple categories meant that there was an obvious
inadequacy in the guidance material. Because there were differing requirements
under each activity’s relevant policy or procedure, without knowing how the
activity fitted into this policy maze, the teachers were not able to define what requirements were to be followed. This demonstrates, prima facie, the inadequacy
of the guidance material that was in place in 2018.
150. Educator 6, a former Campbell High School teacher interviewed by Worksafe ACT, said
in reference to the PE and Sport Activity-Specific Mandatory Guidelines:
“… [this is the] one that I have the least amount of faith in at all because the, because
the requirements that it lists to run some of these activities are just absolute
preposterous.”[201]
[201] Exhibit B.30 (WorkSafe brief), TROC Educator 6, p2673 L42-45
151. Dallat/Salmon stated that the ‘Capture The Flag’ activity on 18 October 2018 was not
planned in a manner to support appropriate risk assessment and management.[202] They
[202] Exhibit E.1 p15 at [3]
also say that the policies were difficult to understand, interpret and apply,[203] and that the
[203] Exhibit E.1 p17 at [8]
risk management systems designed to support the ACT Education Directorate were
inadequate.[204] They suggested the implementation of strategies to reduce the likelihood
[204] Exhibit E.1 p18 at [20]
of such an incident, including developing clear policies, procedures and processes
conducting these activities, adequate communication and training about those policies,
procedures and processes, improved IT system to locate and review those policies,
improved principal induction and support which enables principals to understand risk
management requirements, communication of changes to policies and procedures,
provision of adequate risk assessment methods, adequate and formal communication
and training of risk assessment methods, improved reporting and sharing of knowledge,
feedback mechanism over policies and procedures, and formal networks for sport, PE
and outdoor adventures. [205]
[205] Exhibit E.1 p20 at [26]-[37]
152. Following Adriaan's death, the Director-General of the ACT Education Directorate
commissioned an internal review of the management of all Health and Physical
Education (“HPE”) activities in ACT public schools.[206] The review examined:
[206] Exhibit D.2A, Review Draft Report (p20-61); Exhibit D.2, Statement of Jason Borton, p5 at [15]
(a) All relevant policies, procedures and guidelines; (b) Three other jurisdictions’ policies, procedures and guidelines; (c) Workplace health and safety; (d) Risk management; (e) First aid; (f) Responding to incidents and incidents; (g) Supervision and ratios; (h) Role of school leaders in implementing HPE planning, preparation and approval;
(i) Qualifications and professional learning; and
(j) The role of the Education Support Office (“ESO”).[207] [207] Exhibit D.2A, Review Draft Report, p22153. The review did not make specific recommendations but identified areas of strength and
opportunities for enhancement.[208]
[208] Exhibit D.2A, Review Draft Report, p22
154. During the course of the review, the Director-General of the ACT Education Directorate
decided to establish a Taskforce to implement the agreed findings from this review
including opportunities for enhancing existing practice. The Taskforce was also able to
propose additional enhancements to areas not covered by this review.[209]
[209] Exhibit D.2A, Review Draft Report, p22
155. The Taskforce commenced its work on 4 February 2019 and completed a report in May
2019. [210] According to Jason Borton, the executive lead on the Taskforce, the Taskforce: [210] Exhibit D.2B, Health and Physical Education in Public Schools Taskforce Report dated May 2019,
(a) conducted a systematic review of the policies, procedures and guidelines applicable in the space, including an analysis of the relationship between each
of these documents;
(b) conducted a rigorous review of Health and Physical Education (HPE) activities planned by schools for Term 1, 2019 including risk assessment and
management plans;
(c) consulted with HPE leaders (that is, the most senior HPE teacher leading the HPE faculty for each High and Senior Secondary College) regarding their
professional learning requirements;
(d) collected exemplars of high quality HPE risk assessments and management plans to share with other schools to promote quality practices;
(e) convened a secondary principals’ forum, incorporating an induction package, in March 2019; and
(f) convened in March 2019 a Health and PE Leaders Workshop incorporating an induction package.[211]
[211] Exhibit D.2, Statement of Jason Borton, p6 at [18] & [21]
156. Substantive changes implemented by the Taskforce include:
(a) Schools were required to define their boundaries and school site, having regard to advice that areas of public land and bushland which were outside the school
boundaries and or were separated from the school by a road could not form
part of the school site.[212] Following the completion of this task the Directorate
[212] Exhibit D.2, Statement of Jason Borton, p9-10 at [32]-[38]
formally approved school sites for the purpose of excursions.[213] It is of
[213] Exhibit D.2C, Approved School Sites for the Purpose of Excursions dated November 2020, p185-
particular relevance to this incident that the Taskforce has decided that neither
Reid Oval nor the public land adjacent to the school that forms part of Mount
Ainslie are approved school sites for the purpose of excursions for Campbell
High School;[214]
[214] Exhibit D.2, Statement of Jason Borton, p10 at [36]
(b) Schools were required to prepare risk assessments and management plans for particular activities, with the assistance of example templates and tools
provided by the Taskforce;[215]
[215] Exhibit D.2, Statement of Jason Borton, p8 at [24]
(c) The multiple, overlapping policies and procedures that existed in the PE, sport and outdoor education space were replaced with two comprehensive and
simplified policies and procedures for physical activities and excursions. These
documents[216] had been prepared in consultation with internal stakeholders,
[216] Exhibit D.2D, Physical Activities Policy Suite (Identifier - 00045), p296-411 & Exhibit D.2E, Excursions
external sporting organisations and peak bodies and by having regard to
implementation of Adventure Activity Standards;
(f) In the Inquest into the deaths of IU and BN (unreported, NSW Coroner’s Court, Coroner van Zuylen, 8 April 2011) the Coroner jointly investigated the unrelated
deaths of two 16-year-old girls who died in ski incidents on school excursions
weeks apart at two different NSW ski resorts. Among other things, the Coroner
recommended that all students on school ski excursions be closely and directly
supervised by either teachers capable of skiing with them on the ski run they
are skiing on, or by qualified ski instructors; and failing that, if schools
conducting ski excursions take the view that students may ski without close
and direct supervision by teachers or appropriately qualified persons, the
Coroner recommended that additional requirements be adhered to including a
requirement for written and informed parental consent. The Coroner also
recommended that the Minister for NSW Department of Education and Training
consider his recommendations into the applicable State-wide guidelines;
(g) In the Inquest into the death of SM (unreported, Tasmanian Coroner’s Court, Coroner Chandler, 7 May 2012) the Coroner investigated the death of a 15-
year-old boy who drowned in a river while on a school excursion. The Coroner
found that the activity had been mischaracterised as a minor rather than a
major excursion, and incorrect guidance material followed in that respect;
further there was no formal risk assessment conducted and any risk
management process that had been applied was informal, ad hoc and seriously
inadequate. The Coroner noted with approval that both the Department of
Education and the school involved had taken a number of initiatives to improve
guidance material and safety measures, but found the Department’s failure to
ensure that staff were aware of and fully understood the relevant guidelines as
a factor which contributed to the death. The Coroner also found that the
supervising teacher failed to properly supervise the activity and this was a
factor which was contributory to the death;
(h) In the Inquest into the death of Kyle VASSIL [2014] VicCorC 188 Coroner White investigated the death of a 12-year-old boy who drowned while on a school
camp. The Coroner found that there had been no risk assessment conducted
and the guidance material and training for teachers was inadequate, but these
things were self-rectified by the school prior to the inquest hearing. Among
other things, the Coroner recommended that Education Department guidelines
on water-based school activity (which were described as ‘first rate’) be
commended to independent schools, and that potentially compliance with
those guidelines be a condition of registration for all schools in the State; and
(i) In the Inquest into the death of Jethro Ngalarra Dhamarrandji-Baker [2016]
NTLC 021 Coroner (and Judge) Cavanagh investigated the death of a 12-year-
old boy who was run over by a vehicle being pulled by rope during an activity
at a school carnival. The Coroner found that there was no written risk
assessment of the activity, and an incomplete understanding of the hazard
detection and mitigation processes required by the Work Health and Safety
Legislation.
In light of this extensive history and the failures of training, process, policies and
procedures detailed above, I find that the inadequate processes and procedures
at Campbell High School and the ACT Education Directorate as at October 2018
constitute a matter of public safety.
E. A CONSIDERATION OF SECTION 58 188. At paragraph 9 of her most recent statement[264] Sandra Roodt stated “We are also
[264] Exhibit C.4 265 Exhibit C.4
hopeful that the coronial process will help us to understand the decision of the
Department of Public Prosecutions and WorkSafe not to pursue a prosecution of the
director it for breaches of the Work Health and Safety Act. The process involved in the
investigations leading to that decision took two years and the decision was so different
to what we had expected that we think the findings from this inquiry should be looked at
when it is all done to see if that decision should be reconsidered.”
189. Section 58 of the Act relevantly provides:
(1) Subsection (3) applies if, during an inquest or inquiry, a coroner has reasonable grounds for believing that, having regard to the evidence given at the inquest or inquiry, a person mentioned at the inquest or inquiry has committed an indictable offence.
(2) For subsection (1), the coroner must have regard to—
(a) the admissibility at trial of the evidence given at the inquest or inquiry; and (b) whether the director of public prosecutions, or a person who may be affected by the referral to the director of public prosecutions of evidence relevant to the alleged offence, is, or has been, given the opportunity to present or give evidence in connection with the alleged offence.
(3) The coroner—
(a) must, by written notice, tell the director of public prosecutions about the coroner’s belief; and
(b) for a related indictable offence—must not proceed further with the inquest or inquiry until the day worked out under section 58A, other than to
establish the following facts:(i) for an inquest—the death of a person, the person’s identity and the date and place of the person’s death;
(ii) for an inquiry—the date and place of a fire or disaster.
(4) A coroner must not continue holding an inquest or inquiry if satisfied that the
inquest or inquiry should not be continued.(5) In this section:
related indictable offence, in relation to an inquest or inquiry, means an indictable offence that raises the issue of whether a person caused a death, suspected death, fire or disaster the subject of the inquest or inquiry.
190. While the Act provides that a Coroner must stop an inquest if the Coroner believes a
related indictable offence has been committed, it is a matter of discretion as to whether
the inquest should be stopped in the case of forming a belief about the commission of
summary offences.
191. The WorkSafe brief was previously submitted to the Office of the ACT Director of Public
Prosecutions (“ODPP”) for consideration of bringing charges in relation to Adriaan’s
death. On 9 October 2020, the ODPP formally advised WorkSafe ACT they would not
be instituting proceedings in this matter due to insufficient prospects of conviction: see
Exhibit B.2, p20. I do not know the Director’s specific reasons for declining to proceed.
I acknowledge the Roodt family’s concerns about the lack of a prosecution in relation to
Adriaan’s death.
It is a matter for the Attorney-General whether he chooses to follow up the decision
not to proceed with a prosecution, but it should be noted that the Roodt family
seeks a reconsideration of that decision.
F. SECTION 55 194. Subsection 55(1) of the Act provides as follows:
A coroner must not include in a finding or report under this Act (including an annual report) a comment adverse to a person identifiable from the finding or report unless the coroner has, making the finding or report, taken all reasonable steps to give to the person a copy of the proposed comment and a written notice advising the person that, within a specified period (being not more than 28 days and not less than 14 days after
the date of the notice), the person may—
(a) make a submission to the coroner in relation to the proposed comment; or (b) give to the coroner a written statement in relation to it.
195. The Territory has invited me to serve notices on the school staff, but I do not find that
this is necessary.
I find that the evidence does not rise to a level that would properly support an
adverse comment or finding against any of the staff at Campbell High School. I
served a s 55 on the Australian Capital Territory and submissions were received. I have
taken those submissions into account when making my findings.
G. FINAL COMMENTS
The Directorate failed to correctly administer their policies for excursions and
activities at the time of Adriaan’s death. There was insufficient clarity about policy
that existed, the policies were difficult for teachers to access, insufficient training
was provided for leaders and teachers about those policies and insufficient
compliance checking was conducted by or on behalf of the Directorate.
The failure to have conducted an adequate risk assessment or risk assessment
and management plan represents a lost opportunity to have conducted the
‘Capture The Flag’ activity in a different way. An adequately conducted risk
assessment or risk assessment and management plan should have resulted in a
different outcome for Adriaan and his family. That is a reasonable expectation of
policy by parents who place their children in the care of the Directorate.
Once the decision was made to conduct an activity at Remembrance Memorial
Park, the only way in which the incident causing Adriaan’s injuries would have
absolutely been prevented is by an activity different to ‘Capture The Flag’ having
been conducted, or a different location chosen, or if there had been closer
supervision of each student.
I find that with greater supervision Adriaan’s death was preventable. Within the
field of play and near to a gaol - an obvious and important geographical place
within the game - the schoolboys became mischievous and misbehaved. They
made multiple attempts to lift the log. That whole log lifting activity cannot have
been only confined to mere seconds. Adequate supervision should have swiftly
resolved this behaviour and ensured a very different outcome for Adriaan.
However, as I have noted, this is not intended to be a criticism of the individual
teachers. I have found that the deficient risk assessment processes that were in
place at the time did not produce an outcome that had sufficient staff on the
ground to ensure that appropriate supervision took place.
H. RECOMMENDATIONS 201. At paragraph 8 of her most recent statement265 Adriaan’s mother Sandra Roodt said:
“We are hopeful that the outcome of the Coronial process will be recommendations
which will result in the improvement of processes within the educational directorate to
prevent another child sustaining an injury during a supervised outdoor education
session.”
202. Educator 9 also told investigators during her interview:
“… I mean, I hope that some really nice, strong, clear directions can come out of this
around future policy because you know your worst nightmare … is to have a child
die in your school and it’s certainly been an incredible effect on that team at
Campbell.”[266]
[266] Exhibit B.30 (WorkSafe brief), TROC Educator 9, p2425 L5-8
203. It is clear to me that major policy changes that serve to honour those hopes have been
put in place by the Directorate.
I make the following recommendations that flow from my comments:
(a) 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.
(b) 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 of the
date of these findings.
(c) 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.
I. RECOMMENDATIONS SOUGHT BY THE ROODT FAMILY
Adriaan’s family has asked that I make the following further recommendations.
The Territory has received advance notice of them and, in submissions, did not
objected to them. They flow from my earlier comments and observations about
the Work Health and Safety Act 2011 above and I endorse them:
(a) 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
that has been adopted by the ACT Government[267].
[267]Adopted in ACT law by the Work Health and Safety (How to manage Work Health and Safety Risks
(b) 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; and
(c) 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.
J. OTHER MATTERS
206. I wish to make an observation. During the conduct of this matter, I have had the
opportunity to watch, read and consider the Roodt family’s responses to COVID
interruptions and other delays, their terrible individual stories of overwhelming grief and
loss and the manner and poise with which they have conducted themselves throughout
their navigation of these proceedings. There is nothing that would make me think other
than Adriaan was cut from that same cloth as his parents. He was dearly loved and liked
by many. I can only conclude that the ACT and Yass communities have lost a bright
young person with a bright future ahead of him and that Adriaan was quite a man in the
making.
I express my sincere condolences to the Roodt family and to Adriaan’s loved ones and
friends.
I certify that the preceding two hundred and seven
[207] numbered paragraphs are a true copy
of the Reasons for Decision of his Honour
Coroner Stewart.
Associate Rebecca Hunter
Date: 17 March 2023
SCHEDULE OF ACRONYMS
ACT – Australian Capital Territory
ACTAS - ACT Ambulance Service
ACTFR - ACT Fire and Rescue
CA – counsel assisting
CPR – cardiopulmonary resuscitation
PE – physical education
WHS – work health and safety
Educator 1, p2294 L33-35; Exhibit B.30 (WorkSafe brief), TROC Educator 9, p2410 L23-37 & p2414
L14-20; Exhibit B.29 (WorkSafe brief), TROC Educator 8, p2379 L9-26, p2390 L33-36, p2393 L24-27
(WorkSafe brief), p2325-6
students who were interviewed by the AFP and by the teachers interviewed by the AFP & WorkSafe.
Educator 4 TROI, 2240 (lines 15-20 and 35 - 40).
Educator 4 TROI, 2232 (lines 35 - 40).
Educator 4 TROI, 2229 (line 35).
(answers to questions 99 – 103).
brief), Educator 4’s minute at p2281
brief), Educator 4’s minute at p2281
“I thought it for a long time and I think we all have and I think we've discussed different issues
and we've also tried to alleviate those issues by moving around and being actively supervising
those areas and stopping any stupid or silly behaviour as soon as we see it.”
5, p324 at A11:
“I was standing up, sort of further up the hill within the boundaries that we set. But yeah, further
up the hill looking down.”
Also Exhibit B.26 (WorkSafe brief), TROC Educator 4 at p2229 L45-2230 L3 & maps at p2279-80:
“Towards the end of the lesson I was up the top supervising with my colleague Educator 5 . I
saw Educator 3 jogging up towards one of the extremities of the game, like I can have direct
line of the teachers down the bottom of the field, so I started walking down.”
2230 (lines 44 to 1).
2, p313 at A151-3:
“Um, so, um, as I kind of stated before, I was standing there with Educator 1 and Educator 3.
Um, they were probably just a tiny bit closer to the side that the incident happened. Um, and I
think that’s probably why when the – the kids kind of came jogging, and were, like – basically
said, “Oh, a student’s been hurt. Um, you need to come and have a look.
“We have a couple of teachers up the top of the course. Um a few teachers were down the
bottom, and I was about midway.”
“You can see fairly far into the field of play. But definitely it’s restricted enough so that we
couldn’t see the – what the incident that happened or wouldn’t have, um – if a student didn't
come over or we didn't hear something, we wouldn’t have seen it basically.
“What you need to understand is that those boys I believe were trying to evade our sight, if that
makes sense, because they were doing – they were – if you can see where they are – this would be the hardest – this would be one of the hardest places in the whole area to be seen,
if that makes sense. So, they've actually started here, where it's clear, moved around, looked
around and then found a log out of sight and that's what they've done.”
“I have seen kids pick up a stick, for example, and I've said, "Put the stick down" straight away.”
“Um, so we were all up on the mountain playing ‘Capture The Flag’ with school, and we’d all
been captured and put in the jail …”
Also at p259, A 61 & 63. See also Exhibit A.30 (AFP brief), TROC SC (Part 2) at p394 A9-10. See also Exhibit A.32 (AFP brief), TROC EM at p445 (A25-26), p449 (A75), p464 (A276), p467 (A320-321, 330- 331), p469 (A356-357), p470 (A361-363), p474 (A427) as well as contemporaneous (1.5-2 hours later) handwritten statement at p480-2. See also Exhibit A.11 (AFP brief), TROC KN at p209 (A11), p212 (A50-59), p213 (A62-63). See also Exhibit A.15 (AFP brief), TROC SS at p285 (A15-17), p288 (A52- 55).
“Q276 So where was the – so this log you described. Can you mark that on here for me?
A This was here in, like, the jail where we were.
Q277 Okay. So inside the cones. Yeah.
A It was inside the -it was- yeah. Relatively…..”
See also Exhibit A.6 (AFP brief), TROC TC at p51:
“Q36. Can you describe this tree for me?
A It was probably just – it was, like – just, like, a dead tree on the ground. I don’t know how big
it was, but.”
See also Exhibit A.11 (AFP brief), TROC KN at p213:
“Q62. Okay. So where was this log that you described in relation to - - -
A KN: It was, like, lying in the jail area.
Q63. Okay. Can you describe how – what the log looks like?
the ground. It wasn’t really heavy. It was just awkward weight.”
See also Exhibit A.31 (AFP brief), TROC MQ at p436:
“Q355. Okay. Okay, and this log, like, where was that in relation to the jail area?
A Um, it was pretty close to the jail.”
See also Exhibit A.15 (AFP brief), TROC SS at p298:
Q204. Yep. So you were about two metres away and you saw everything.
A Yeah
Q205. Do you know what prompted them to lift the log?
A No.
Q206. No. Were they still playing in the game, per se? Or - - -
A Yeah. In the prison, you can’t move outside of it.
Q207. Gotcha.
A So you just have to wait there. . (cont.)
Q208. Do you mind putting the cones around where you sort of remember? So I take theunderstanding is that the log is outside that bounds.
A Yeah.
Q209. And you said there was some bushes in front of the log.
A Yeah.”
• A.8, Images taken by Fallon, specifically p149 & p191-193 • A.9, Case Note Entry by Trebilcock, specifically p195
attempt to lift the tree, at A102-103
refers to 4 attempts before the fatal incident at p480-2.
p480-2.
p480-2.
p480-2.
p480-2.
• SC states that pressure is being applied to the bleeding spots at Q15, which is 1:57 of the
recording minus 9 seconds for the time stamp, this equates to 10:52:28
• SC confirms to 000 that Adriaan is in the recovery position at Q27, which is 3:26 minus 9
seconds for the time stamp, this equates to 10:53:57
• Teacher comes on the line at Q41, which is 4:53 of the recording minus 9 seconds for the time
stamp, unequivocally puts a teacher (Educator 1) at Adriaan’s side at 10:55:24
call transcript.
TROC Educator 3, p223 at A16
“Within, I don’t know, timewise, time’s just – it was out there, it was happening, I suppose,
timewise, so I can’t be exact on those things, but within about thirty seconds or so of me doing
that quick assessment [of Adriaan], turning him onto his side and, ah, then starting to check for
his breathing, a lady came down the … walking path that goes up Mount Ainslie…”
p506 at [13]
of Dr Hall, p359 at [4]
• A.21, Images taken by Scott (separately included in brief due to distressing content) • A.22. Case Note Entry by Wensing, p353-356
• A.8, Images taken by Fallon, p89-193 • A.9, Case Note Entry by Trebilcock, p194-195
L7-16
Educator 9, p2412 L14-27
171 Exhibit B.21, ACT Education Directorate Physical Education and Sport Policy, p2094 at [5.1](definitions)
[3.25]
B.22, ACT Education Directorate Physical Education and Sport Procedures, p2098 at [3.3]
Guidelines, p3013-4 at [22]
[3.30]
the game when played on Mount Ainslie surprising, and attributes this to good fortune rather than good
management: see Exhibit E.2, p27-8
10 February 2023, paragraph 65.
p62-184
295
Policy Suite (Identifier - 00046), p412-429
TROC Educator 7, p2339 L6-10; Exhibit B.27 (WorkSafe brief), TROC Educator 1, p2301 L19-22 & p2323 generally; Exhibit B.29 (WorkSafe brief), TROC Educator 8, p2377 L1-8
provided to the Coroner. Unreported cases referred to in these findings have been anonymised for
publication.
remained open and under investigation as at the date of the report, such as the Victorian death in which
the prosecution has recently been completed: see Annexure B, p50.Code of Practice) Approval 2020.
Key Legal Topics
Areas of Law
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Coronial Law
Legal Concepts
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Unjust Enrichment
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Duty of Care
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Negligence
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Risk Assessment
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Supervision
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Causation
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