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School fined following death of pupil with special educational needs

17 January 2025

A recent HSE prosecution has resulted in a £300,000 fine being imposed on a school academy trust, after a 19-year-old student died as a result of a “series of management failures”. The case is a reminder of the potentially significant, and tragic, consequences which may arise from a failure to develop and implement adequate risk management procedures, especially in the education and disability sectors.

Summary of case

Owen Garnett, a sixth-form student, attended Welcombe Hills School in Stratford-upon-Avon, a school for students with special educational needs which is part of the United Multi Academy Trust (“Unity MAT”). Mr Garnett had been diagnosed with Pica – an eating disorder which causes people to eat non-food substances that have no nutritional value, such as paper, soap, paint, chalk, or ice. In January 2023, Mr Garnett died after choking on a paper towel during a break from class at Welcombe Hills School.

An investigation conducted by the HSE following Mr Garnett’s death found that none of the staff in Mr Garnett’s class team had received any specific training on the management of safety risks associated with Pica. Moreover, just days before the fatal incident, there had been a similar “near miss” incident involving Mr Garnett. On that occasion, Mr Garnett was seen by a teacher in the school playground choking on blue towel. The HSE found that the school had:

  1. Failed to ensure that all safety risks associated with Pica hazards, such as paper towels, were correctly identified, and that appropriate preventive and protective measures, including supervision, were organised in such a way as to protect Mr Garnett
  2. Failed to effectively investigate and respond to concerns which had previously been raised by Mr Garnett’s family.

The HSE found that the risk of choking associated with Pica had been identified in an individual risk assessment prepared by the school in relation to Mr Garnett, and a “named person” was required to supervise Mr Garnett to ensure he did not eat anything that could cause him harm. This control measure was clearly not adequately implemented.

The HSE prosecuted Unity MAT in respect of a breach of section 3(1) of the Health and Safety at Work Act 1974 (Act). This section imposes a duty on employers to conduct their “undertakings” in such a way as to “ensure, so far as is reasonably practicable” that persons not in their employment are not exposed to risks to their health and safety.

Unity MAT pleaded guilty to breaching section 3(1). On 18 December 2024, at the Coventry Magistrates Court, Unity MAT was fined £300,000 and ordered to pay £10,750 in costs.

Key takeaways

This case serves as a stark reminder to schools of the grave consequences which may arise from a failure to implement adequate risk management protocols and procedures, particularly with respect to vulnerable individuals such as pupils with special educational needs. The case reinforces that:

  1. When the conduct of a health and safety risk assessment regarding individual students is required, schools should adopt and follow a risk management approach that focuses on the “real risks”. Schools should involve employees, pupils where possible and carers in identifying individual needs and control measures designed to address them.
  2. It is imperative that schools provide specific training for staff on the individual risks and needs they are likely to encounter in the course of their employment. In this case, it was found that none of the staff in Mr Garnett’s class team had received training on the specific risks associated with Mr Garnett’s condition.
  3. Following “near miss” incidents, schools should undertake a rigorous health and safety reviews to identify, and then implement, protective or preventive measures to address the risk of recurrence. In cases involving a failure to introduce protective or preventive measures following “near miss” incidents, it is far more difficult to argue that an employer has adequately discharged their duty under section 3(1) of the Act.

Further information regarding the prosecution of Unity MAT has been published by the HSE here. The HSE has also published specific guidance on supporting pupils with disabilities, special educational needs and additional support needs.

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