Coroner finds slack OHS was partly at fault
CORONER Nick Reimer yesterday recommended Trinity Catholic College Lismore overhaul its occupational health and safety systems following the death of a five-year-old boy at the school about 18 months ago.
Gabriel McBurney was crushed to death on October 17, 2005, when a 100-kilogram gate at the school's Brunswick Street entrance rolled free from its restraints and fell on him.
In November last year Mr Reimer presided over a three-day inquest into the accident. He made the recommendation yesterday as he handed down his findings.
Mr Reimer said the evidence clearly indicated no one had committed an indictable offence ? an offence for which they would likely be charged ? emphasising the proceedings were not intended to prosecute anyone nor were they a civil action for damages.
Neither police nor WorkCover NSW investigators had recommended anyone be charged over the accident.
However, in his general findings Mr Reimer said the gate, installed by Northern Rivers Fencing Pty Ltd in October 2003, was deficient from the start and while its problems had become apparent from at least January 2004, they had never been sufficiently rectified.
The first of several reports of the gate actually rolling past its stoppers and falling was in February 2004 when it did so on to Gabriel's father Greg McBurney, an employee of the school.
Mr Reimer was satisfied on the evidence presented there was 'sufficient knowledge and experience as to the malfunction in the gates and the inherent danger they posed during 2004 and leading up to the incident on October 17, 2005, to have caused the management of Trinity Catholic College to have acted to remedy those problems'. The school did have an internal computer network and other OHS systems designed to resolve such problems, Mr Reimer said.
"It seems staff were insufficiently indoctrinated in the workings of these systems so the essential problems regarding this gate were never properly reported or documented and the system, which was no doubt well-planned by people who were well intentioned, simply fell down when it came to the danger evident in the condition of the subject gates," he said.
"It seems the system was sometimes followed and sometimes bypassed by verbal reports of problems and verbal instructions for rectifications.
"Additionally, there seems to have been no effective supervision or follow up of maintenance or rectification work nor any effective audit of safety or maintenance requirements. I am sure the knowledge gained in hindsight by the school's management will ensure strict compliance in the future."
Trinity principal Brother Peter Pemble said yesterday the school always supported a public inquiry into Gabriel's death.
"It is now up to us to take the coroner's recommendations and act upon them in the best interests of the entire Trinity community," he said.
"The personal safety and well-being of our students, staff and their families are of utmost importance to us. We will continue to build upon and improve existing processes to ensure a tragic accident like this never happens again.
"We take the comments of the coroner very seriously and commit that we will do everything we can to take on board his recommendations.
"I will be meeting immediately with the OHS committee, and indeed all staff, to discuss each of his recommendations in detail and how best to respond to these in the best interests of the school community.
"The Catholic Education Commission and the NSW Department of Education will be made fully aware of the Coroner's findings and receive any further input they may require from the college."
Mr McBurney yesterday said he was satisfied with the findings.