Safety on School Visits .- Lessons to be learned from the death of a child.
The Health and Safety Executive, the UK Regulator of Health and Safety have published a report on the death of 10 year old Max Palmer on an educational visit in 2002.
The HSE is analogous to the OSHA and has a remit to investigate accidents and to prosecute under safety law.
Max was killed in a "plunge pooling" incident in the Lake District in Cumbria in England's beautiful Lake District. The Lake District is popular with schools for outdoor activities for English schools and Max was killed during one such trip.
The weather was poor, the river was in spate and the water was very cold and arrangements were unsatisfactory.
This report summarises the very detailed investigation into the circumstances around the incident by the HSE and the Cumbrian Police.
The investigation subsequent to the accident led to the prosecution and jailing of the teacher in charge of the visit for one year on a manslaughter charge.
HSE highlights in its report the fact that the report is produced to:
"Prevent further tragedies, not to blame."
The Legal Position
In the UK reponsibilities are apportioned as follows between Schools, Employers(usually Local Councils) and Teachers as follows:
*Employers are responsible for ensuring the effective management of Health and Safety.
*Teachers, Heads and Managers are responsible for the Health and Safety of pupils both when they are on school premises or when they are offsite on authorised school activities elsewhere.
This responsibility is actually written into national teacher's conditions of service and is also part of the Common Law "duty of care" owed by one person (or body) to person not to act, or fail to act, so as to avoid causing harm.
So what are the causes of this incident and what are the lessons which can be learned from it?
Causes:
The Investigation identified two main causes for the tragedy:
1. The actions of the teacher in charge of the activity, before and during the incident.
Amongst a range of shortcomings we can highlight the following:
The teacher who led the visit joined the school in 1998 as Head of Geography and claimed to have "Mountain Leader Award", in fact subsequent investigations showed he had not successfully completed this award.He was also inadequately trained in First Aid.
His actions contravened normally accepted good practice and whilst teachers from another school staying at the centre actually cancelled activities because of local conditions he allowed water based activities to go ahead in water temperatures of 47 degrees Fahrenheit.There was an inadequate and no ongoing Risk Assessment.
The levels of supervision were inadequate. The apparent ratio was 1 Adult to 5 Children but actually neither of the other adults were experienced and so the level was actually 17:1.
The Emergency Response was inadequate when the emergency actually occurred the teacher tried to save Max but quite quickly succumbed to the cold and when he got out of the water took no further part in the rescues.
The protective devices needed were not available, there was an attempt at rescue with a "rope" made of knotted towels.However,it was not until a pupil was sent to fetch a rope from the activity centre being used by the trip that the alarm was raised.Teachers from another school brought emergency rescue equipment and were praised in their conduct by the report.
2.The weaknesses of the safety management system which allowed the trip to go ahead and an unsuitable leader to be in charge of children doing a high risk activity in difficult environmental conditions, without adequate precautions.
A range of safety management shortcomings were identified but whilst these may have contributed to allowing the incident to happen they did not cause the incident.
The key point is that Health and Safety needs to be managed effectively both by the employer and by the school.
Defects which allow The fact that a teacher could be appointed as a leader when not adequately qualified or competent to lead, is highlighted by the report.
What are the Lessons to be learned ?
The main lessons can be summarised as follows:
1. Leaders of outdoor activities in schools need to be competent and diligent always putting the safety and wellbeing of the children first.The Employer and the School need to determine who will check qualifications and competence.
This means that ALL the adults who accompany a visit need some form of training and any Leader needs to be competent for the activity they are supervising.Competent when used by Regulators generally relies on Lord Cullen's definition in the "Piper Alpha Report" and means "sufficient knowledge skills, experience and qualities" it also means "appointed in writing". A leader will be a person who can carry out a meaningful and relevant risk assessment on the spot and considering local conditions because they "know" the activity planned.
This doesn't mean that every "leader" i.e adult going on a trip has to be a mountaineer or an expert skier... people will have different levels of competence but all adults on a trip should have at least basic visit and safety training.
A suitable qualification for newer teachers and classroom assistants which covers visits and the range of School Safety is the College
of Teachers Certificate of Educational Studies - School Safety I.
This can be viewed at www.swaneducation.co.uk.
2.Visits should always take place under the aegis of "good practice" and schools need to be sure that they either have "in house" or have access to suitable personnel to deliver this.This means that a list of approved visits is maintained and a procedure is set up to accept/reject new "activities" proposed.
To see what "good practice" looks like in the UK for school visits this is set out in the following free documents:
DfES - Guidance on Educational Visits (1998) and it's 2002 supplements available at http://www.teachernet.gov.uk/wholeschool/healthandsafety/visits/
The Scottish Executive Education Department has also issued relevant guidance - "Health and Safety on Educational Excursions" which can be available at:
http://www.scotland.gov.uk/library5/education/hsee-00.asp
3. Schools need to have effective management systems in place with suitable policies to ensure that proper planning and preparation of visits goes ahead under clear policies and procedures.
The Glenriddings Report highlights some important ones:
Approval,Parental Consents, Bringing External or Related Children on Visits, Supervision on Visits,Medical Conditions, Swimming, First Aid etc.
4. Favourable comments from Inspectors (in England and Wales OFSTED) about educational visit programmes are no warranty that the visits or practice are safe and are certainly no substitute for thorough Risk Assessment.
5 Headteachers can delegate safety functions(NB not responsibilities) but need to establish clear lines of accountability. Every School should have a person responsible for Health and Safety.For a way to distribute Safety Management see http://www.swaneducation.co.uk - College of Teachers Accredited Training Certificates of Educational Studies - School Safety II). This includes an Option on Educational Visits, and others on School Risk Assessment,School Safety Training and School Safety Committee Operations.
6.All Educational Visits need to be operated through the continuing assessment of risk. Risk Assessments need to be relevant,have a clear regard to supervision levels and consider how the party would respond in case of an emergency. The two key words here are relevant and continuing. The report clearly showed that the Leader was not competent to make a Risk Assessment, so any Risk Assessment done by him was flawed.The Risk Assessment did not take account of the local conditions so it was not a continuing, ongoing or dynamic Risk Assessment. Some other shortfalls identified included the levels of supervision and the impact that this, and the lack of emergency planning had on the outcome of theincident.
7.The Employer and the School need to clarify between them who supplies "Generic" who "specific" safety training to avoid confusion.There also needs to be clarity on who checks qualifications and competence as this problem
8. Governors and School Boards are "informed friends" of the school and Governors carry out a role analagous to non executive directors in companies.The lesson to be learned from the report is that Governors need to be trained as to what questions need to be asked and Head teachers need to be sure that the Governors are asked for approval well before any visit is planned. The Governor's role is to probe the logic and value of the trip and to act to check that all precautions are in place.
9.Monitoring and audit provide mechanisms whereby the compliance with School and Employer Safety Systems can be checked. In addition to normal in school monitoring by Govenors and the Head, it is also recommended that field monitoring of visits should be undertaken.
In conclusion, the report on this tragic incident gives all of us in Education food for thought and in many cases one hopes a timetable for action.
It is impossible to manage safety without a system to manage within but I do welcome HSE's support for distributing some of the safety management functions.
HSE in the report also drew attention to the delivery of major and important documents to Head teachers without a support infrastructure.
Pieces of paper are NOT a system. Any system of safety management needs to be "owned" by the school.
Heads get hundreds of documents year all of them are important but they need time and/or tools to manage effectively.
This is why I produced a Headteacher's Safety Management Toolkit....
I hope that it and shortish briefing papers like this which I provide free from time to time will help provide some focus and some of that support.
About the Author
Dr. Paddy Swan is a qualified teacher with some 25 years safety experience in industry and has produced 100 safety training and management systems for international corporates. He is currently the Principal Consultant of Swan Education which is an Accredited Centre of the College of Teachers. Paddy is the author of the Open Learning materials for the College's Certificate of Educational Studies (COES I &II School Safety) www.swaneducation.co.uk
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