Duty of Care: Safeguarding Against Harm

A Coronial Inquest into the Death of Cristiaan Adriaan Roodt

On 17 March 2023, the Coroners Court of the Australian Capital Territory handed down a decision into the death of Cristiaan Adriaan Roodt (Adriaan), the full decision can be found at this link (Decision). The events which led to Adriaan’s death, following a horrific accident during a school PE activity on 18 October 2018, highlights the importance of schools having appropriate policies and procedures in place to safeguard and protect children from reasonably foreseeable risks of harm.

In this case, Coroner Stewart found that the death of Adriaan was a direct result of Campbell High School and the ACT Education Directorate (Directorate) not having clear guidance from existing policies and procedures, which led to inadequate supervision and poor risk assessment, management and mitigation. Coroner Stewart found that if appropriate policies, procedures and guidance had been in place the risk which led to Adriaan’s death would have been reasonably foreseeable and therefore avoidable.


Adriaan was a student in Year 10 at Campbell High School. On 18 October 2018 at 10:00am he attended the school gymnasium for physical education. 112 Year 9 and 10 students, including Adriaan, and five teachers left the schoolground and went to Remembrance Memorial Park at the base of Mt Ainslie to play a game called ‘Capture the Flag’.

Teachers conducted a risk analysis of the area prior to the game being played to assess if the area was safe. In addition to the risk analysis of the area, teachers possessed a first aid kit and mobile phones and completed a verbal safety briefing with students to explain the rules of the game, safety rules and that any ‘silly behaviour’ would be reported to teachers. There were several observation points for teachers to supervise the game and teachers walked around the game field to monitor the game. Due to the incline and dense bushland of the game field, the ‘gaol area’ where the accident occurred, was not in line of sight of the supervising teachers.

At 10:45am Adriaan and some other students were in the gaol area. The students in the gaol area noticed a large log (6.03 metres long and 188.5 kg in weight) and attempted to pick up the log. It is reported by the students that the log was pushed greater than 45 degrees and began to slip. All the students jumped out of the way except for Adriaan. The log fell and struck Adriaan in the head. Adriaan was reported to have been knocked unconscious and had blood coming from his ears, nose and mouth.

A teacher reported hearing a scream and saw a number of students run, but no teacher saw the incident occur. Teachers arrived on the scene and an ambulance was called at 10:50am. A registered nurse came by the scene and commenced CPR while removing blood from Adriaan’s mouth. Paramedics arrived at 10:59am and Adriaan was transported to hospital. Adriaan stopped breathing en route to the hospital and CPR was administered again. On arrival at the hospital Adriaan underwent intubation and resuscitation, while a CT scan showed ‘severe brain and skull injurie (sic), a severe spinal cord injury and a fractured mandible’. Doctors concluded that ‘there was no appropriate surgical intervention available and that Adriaan’s injuries were not survivable’.

Adriaan was pronounced dead at 2:56pm and his cause of death was assessed to be a result of ‘circulatory failure, secondary to traumatic brain injury consistent with blunt force trauma to the head’.

The Inquest

Following a review of the policies and guidelines in place for physical education, Coroner Stewart found that ‘Capture the Flag’ was not an approved activity and therefore required a risk assessment, management plan and approval from the Principal. Due to the game being played outside of school grounds, it was considered an excursion which required parental permission outside of the enduring permission which was obtained when a student started at Campbell High School.

The policies and procedures in place where not complied with and during interviews with staff it was clear that most staff were not aware of how to correctly categorise ‘Capture the Flag’ because they were unaware of how to locate the guidance material. Coroner Stewart found that this led to an ‘obvious inadequacy’ because staff were not able to define what requirements were to be followed and training was not provided to them on how to locate and implement guidance to safeguard against incidents of harm.

Coroner Stewart found 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’. However, the incident leading to Adriaan’s death should have been reasonably foreseeable where ‘young people are placed in gaol for an extended period of time without adult supervision’ as it can be predicted that they would be bored and engage in mischief and misbehaviour. While Coroner Stewart did not believe the behaviour of the teachers supervising the game was inadequate, the amount of supervision provided was considered inadequate and reduced supervision ratios could have avoided the incident occurring as it would have led to swift action to disrupt the students’ behaviour.

A number of recommendations were made following the Directorate commissioning an internal review and taskforce in relation to health and physical education in ACT schools. The recommendations included reviewing policies, procedures and guidelines, reviewing all health and physical education activities, creating templates for risk assessments and management plans and engaging employees in appropriate training. Coroner Stewart found that the Directorate acted proactively to rectify issues which led to Adriaan’s death, however, it is ‘powerful evidence of the inadequacy of the materials that were in place’.


In addition to the recommendations made by the Directorate’s taskforce, Coroner Stewart made a number of recommendations, including that:

  1. Specific cohorts of teachers engage in professional development in respect of risk assessments and relevant policies and procedures.
  2. The Directorate should take steps to evaluate the success of the taskforce’s recommendations around enhancing the risk assessment capabilities of teachers and should publish these findings.
  3. The Attorney-General should review the application of work health and safety laws to ensure the safety of children and employees.
  4. The Directorate should review physical education and excursion policies to ensure compliance with work health and safety laws and report to the Attorney-General their compliance with the Model Code set by the state.
  5. The Directorate should develop policies to foster ongoing work health and safety training, compliance responsibility and auditing and provide a report to the Minister within 12 months.

Learnings from the Inquest

Schools and other organisations working with children have a duty of care to protect children from reasonably foreseeable risks of harm. Organisations must proactively take steps to mitigate foreseeable risks of harm, including through the implementation of policies and procedures that align with the child safe standards and ensuring that staff have adequate training to implement those policies. The death of Adriaan is a reminder that safety cannot be assumed because incidents have not occurred previously, and that policies and procedures are in place to ensure the safety and wellbeing of children under the care, supervision or authority of organisations.

How can Safe Space Legal Help?

Safe Space Legal has extensive experience working with schools and other organisations working with children to ensure they are meeting their child safety obligations and can support organisations by:

  • Drafting best practice child safety policies, procedures and codes of conduct;
  • Conducting gap analysis audits of critical incidents;
  • Providing training on legal obligations, duty of care and child safety;
  • Conducting child safety investigations which are compliant with relevant state and territory schemes; and
  • Provide advice on risk mitigation.

Contact [email protected] or call 03 9124 7321 to organise a complementary discussion in relation to your organisation’s child safety and safeguarding needs.

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