Inquest into the death of Bridget Wright

STATE CORONER’S COURT OF NEW SOUTH WALES Inquiry Inquest into the death of Bridget Wright Hearing dates: 19 October 2015 Date of findings: 20 November 2015 Place of findings: NSW State Coroner‟s Court - Glebe Findings of: Deputy State Coroner H. Barry File number: 2014/56521 Representation: Mr J. Harris assisting the Coroner, instructed by Ms L.

Turner.

Mr M. Short representing Alaina and James Wright Mr W. Hunt of Counsel representing the Department of Education, instructed by Mr P. McGhee Findings: Identity of deceased: The deceased person is Bridget Wright Date of death: died on 21 February 2014 Place of death: died at Westmead Children‟s Hospital Manner of death: Bridget was struck by a falling tree branch whilst she was in the playground at Pitt Town Public School.

Cause of death: Multiple Injuries

The Coroners Act 2009 (NSW) in s81 (1) requires that when an inquest is held, the coroner must record in writing his or her findings as to various aspects of the death.

These are the findings of an inquest into the death of Bridget Wright.

Introduction: Bridget Wright was a student at Pitt Town public school. She was in Grade 4. Her sister Abigail was also a student at the school.

During the lunch break, Bridget was in the playground with a friend. They made their way across the concrete area outside the canteen demountable to the toilet block.

As they walked underneath a Eucalyptus tree a large low lateral tree branch broke away from the main body of the tree and fell to the concrete play area underneath, striking students and a teacher.

The branch came into direct contact with Bridget, knocking her to the ground.

First aid was rendered to Bridget who at the time appeared unconscious on the ground. Ambulance officers attended and she was transported to hospital, where she tragically passed away. She was only eight years old.

Bridget was described as a happy and healthy eight year old.

She had won awards in literacy and numeracy and had achieved the Premier‟s Reading Challenge Gold Award in 2013.

She loved horses and excelled at taekwondo.

She had a wide circle of friends and was a much loved young girl.

Her sudden death has had an unimaginable effect on her family, her fellow classmates and the school and wider community.

The grief experienced by her mother, who was in attendance at the inquest was palpable.

The Inquest Under s.81(1) of the Coroners Act 2009, a Coroner holding an inquest is required to determine the following matters when holding an inquest:

(a) The identity of the deceased person

(b) The date and place of the deceased person‟s death;

(c) The manner and cause of their death.

Bridget‟s identity and date and place of her death is un-contentious. The primary focus of this inquest is the manner of her death and the management of trees in school grounds The Evidence At about 1pm on 21 February 2014 the Pitt Town Public School lunch bell sounded and the students and teachers emerged into the playground. Soon afterwards, a number of witnesses reported hearing a loud “crack.” .A large branch of the Forest Red Gum tree had fallen.

Ms Iskric, a teacher at the school, was near the tree with her back to it. She felt something impact on top of her head. She was stuck by part of the smaller branches falling from the tree.

She observed some students underneath a branch which had fallen onto the ground.

She advised a student to have someone call 000. She was helped by other teachers to lift the branch off the two students, one being Bridget the other being Tilly.

As the branch was lifted up, Bridget and Tilly were dragged slowly out from under the branch.

Mr Minton, was also hit on the head by part of the falling tree. He was knocked to the ground. After initially standing, he fell again and lay on the ground awaiting assistance. He was transported to hospital.

Mr Michael Cooper was relieving Principal at the school, the substantive Principal Mr Michael Miller being away on family leave. Mr Cooper did not observe the incident and arrived shortly after.

Mr Cooper observed Bridget on the ground. He confirmed she had a pulse by checking her neck and wrist. He remembered feeling a small response from her after he asked her to squeeze his fingers.

Mr Cooper and another teacher, Ms Pendleton, attempted to stem the bleeding from Bridget‟s head with towels provided by the canteen until the ambulance arrived.

Police arrived by 1.15pm and a CareFlight helicopter arrived at 1.32pm. Bridget‟s condition deteriorated and CPR was commenced at 1.45pm.

Bridget was flown to The Children‟s Hospital at Westmead. On arrival her injuries were assessed to be non-survivable and shortly afterwards a decision was made to cease resuscitation. Bridget was declared deceased at 2.40pm.

The Autopsy A limited autopsy (external examination of the body) was prepared by Dr Liliana Schwartz, Pathologist.

Her report records the cause of death as multiple injuries.

The Tree The tree in question was a Forest Red Gum. It was estimated to be about 90 years old and essentially the school had been built around the tree. Further buildings had been constructed near to the tree including the canteen in 1995 and a demountable classroom in 2011.

The tree was 26 metres tall and the failed branch was about 7 metres long and about 30 cm thick.

Mr Wayne Back, Arborist, inspected the tree the next day. He concluded:  The branch fell because the tree was unhealthy and had significant problems  There was extensive fungal decay at the site of the branch failure, affecting approximately two thirds of the diameter of its base  An aerial inspection also revealed a 3 metre cavity at the base of the main leaders that contained a large bee hive and there was also bracket fungi on a number of the other branches  While these defects would not have been obvious from the ground, there were enough indicators visible from the ground to warrant an aerial inspection.

Following his inspection and recommendation the tree was removed.

Mr Miller, School Principal Mr Miller acknowledged in his written statement and in his oral evidence that it was the Principal‟s responsibility to maintain safety of the school grounds, including management of trees.

Between July and September 2013,there were periods of high winds. Mr Miller observed small twigs falling from the three largest trees on the school grounds, including the Forest Red Gum tree.He marked off the area surrounding the tree with cones to prevent students and staff walking underneath.

Following that period, Mr Miller requested quotes from local tree contractors to assess three of the largest trees within the school boundary.

.

Two contractors did not respond, but a third contractor did attend and provide a quote. That contractor pointed out vertical branches which required attention.

Mr Miller‟s evidence is that he recalls specifically asking about the lower branch (which failed in 21 February 2014) because it was hanging across a pedestrian area.

It is his recollection that the response was that the branch “looks healthy and does not require attention” In addition, the Department of Education(“the Department”) approved a project to allocate vacant land to the school. The work involved the installation of a new perimeter fence. In order to complete this work some of the trees on the perimeter of the school needed to be pruned or removed. The Forest Red Gum was not one of the trees near the proposed work.

Playsafe Fencing was one of the contactors invited to submit a tender for the work..

In October 2013 that company subcontracted to Ultimate Arbor Solutions to trim trees as part of the improvement works.

On 8 October 2013, Mr Nathan Stokes, owner of Ultimate Arbor Solutions, attended the school to inspect the trees to be trimmed for the perimeter fencing.

Mr Miller asked that he provide a quote for any work needed to be done on the three trees.

Mr Stokes agreed that Mr Miller had requested a quote concerning the three trees including the Forest Red Gum. Mr Stokes indicated to Mr Miller that he could provide a quote, but would only do the work if Playsafe Fencing and his company won the contract.

On 10 October 2013, Mr Stokes sent a quote by email to Mr Miller. That quote included the cost of the removal of the branch in question and for removal of major deadwood.

In his oral evidence, Mr Miller stated that he had no indication that there was any danger concerning the branch. He stated: “I was left with the view that it (removal of the branch) was not an urgent matter.

Each contractor referred to dead wood and it was my intention to have the work done at some point” Mr Stokes agrees that he assessed the trees from ground level. In relation to the Forest Red Gum he recalled seeing a large low lateral branch overhanging a play area. It was his opinion that the branch was extended and overweighted and needed to be removed. He made no observation of fungus or decay. He did not see any bee hives.

In his oral evidence, Mr Stokes agreed that he did not say it was dangerous.

Although the branch was overweighted, Mr Stokes‟ oral evidence was that he did not think it was a matter “of pressing urgency” Tree management in Schools Prior to Bridget’s death

At the time of the accident, public schools were allocated a budget of up to $2,000 to cover the cost of tree management. Any costs exceeding that budget were to be directed to the Department‟s Assets Management Unit (“AMU”) for additional funding.

The only guidance and written policies concerning tree management at that time was contained in the Schools Facilities Standards - Landscape Standards dated 1 May 2012(“the 2012 Standard”) The stated purpose of the 2012 Standard was to provide “a general educational and technical guide for planning new and refurbished school environments” Page 13 of that document states the following:  Avoid the use of tree species known to be prone to limb drop, or restrict their use to low use areas  If a specimen of species prone to limb drop exists as a mature tree on site, carefully consider its location relative to the proposed future use of the surrounding area. Review the design and species and assess the suitability for retention, with a view to minimising potential risk.

 Consult a qualified arborist to review existing trees and assess the risk, as well as provide management guidelines and measures to reduce stress and the potential for limb drop.

Significantly, the School Plant Palette contained within the same document includes the Forest Red Gum as a tree that performs well in a school environment: it not being a species nominated as being prone to limb drop.

Mr Perrau, Executive Director, Asset Management, Department of Education acknowledged in his evidence that the guidance given to Principals concerning tree maintenance as at 2014 was inadequate.

The response by the Department of Education Following the tragic circumstances of Bridget‟s death, the Department responded immediately.

Mr Peter Johnson Relieving Deputy Director-General, Corporate Services, caused an advice to be issued to all Principals in NSW public schools which , in effect directed them to engage qualified arborists as soon as practicable to review the safety condition of trees, with priority to be given to tall trees and gum trees.

Mr Johnson caused a further three emails to be sent to all Principals detailing additional instructions to Principals about tree management.

Further, the Department instructed a safety expert, Ms Catherine King, to examine the circumstances of Bridget‟s death and to provide advice to the Department about future management.

Ms King nominated 6 recommendations that can be summarised as follows:

1. A site risk assessment should be conducted in schools and should be performed by qualified arborists. The assessment to include the health of the trees that are identified to be in high risk target zones and any risk treatment options. Informed decisions to be made about pruning or removal of any affected trees and the frequency of any ongoing surveillance of affected trees.

2. The AMU (local Asset Management Units) to compile a register/record of schools that are identified as having trees with high risk target zones. Records of those trees to be kept for the lifecycle of the trees

3. Contractor specifications for the installation of all demountable buildings and other buildings in schools must include a tree target zone assessment.

4. The Department to consider engaging horticultural experts to prepare a tree planting guide or plan for Principals.

5. The WHS ( Work Health and Safety) Directorate to review and update WHS excursion risk assessment guides.

6. The Department in consultation with their psychology service providers to consider developing and issuing a post-traumatic incident management plan.

All these recommendations have been implemented or are in the process of being implemented.

As a result of these actions, over 9,000 trees have been removed from public school grounds across the State.

New policies have been implemented to assist Principals in their responsibilities concerning tree management.

The system now in place requires a Principal to perform an annual visual tree assessment and to note any changes or defects in the tree since the arborists assessment.

A document entitled Tree Management Guidelines was issued by the Department in April 2015.It is a document designed to assist lay persons such as School Principals to complete a visual inspection of trees in their school environment.

Mr Perrau told the inquest that he was confident that this information now available to Principals, which was compiled with the assistance of industry experts, would assist Principals to fulfil their responsibilities.

Mr Perrau believed it was appropriate to leave this responsibility with the School Principal and not with an arboriculturist. He was of the view that the Principal should maintain control of the assessment and needed to have a level of engagement with the management of trees with departmental support. It is always available to Principals, to obtain expert assisitance if there is a particular concern.

These assessment reports will be recorded by the Department and will be updated each year. Mr Perrau stated that an audit will be conducted on a number of Principals‟ reports that are completed concerning tree assessment in order to guage the quality of those reports and if necessary, recommend improvements.

A further document entitled Educational Standards and Guidelines 2015 dated 6 May 2015 lists matters to be taken into account in Landscape Planning and Design.

That document incorporates some of the principles outlined in Ms King‟s report but also recognises the need to incorporate the use of trees in the school landscape, not only to provide a „sense of place‟ within the school environment but to provide important shade to outside areas.

Mr Perrau told the inquest that every five years AMU attend each school to assess the state of buildings. He proposes to recommend that at that time, an assessment be made of the trees in the school environment by a qualified arborist.

Conclusion All the evidence suggests that 21 February 2014 was a fine and beautiful day with no wind. There was nothing to indicate any specific concerns about the large Red Forest Gum tree in the playground on that day.

What is clear from the evidence is that it was known that the large branch which failed was extended with significant end weight.

Mr Miller had obtained an opinion about the tree from two arborists, the second one being Mr Stokes.

Neither Mr Miller nor Mr Stokes was of the belief that the tree was dangerous. If Mr Miller had been of that belief there is no question that he would have taken immediate action.

On the evidence there can be no criticism of Mr Miller.

Bridget‟s death was a tragic accident.

What is also clear and acknowledged by the Department is that at the time there was little by way of policies and guidelines to Principals concerning the management of trees in a school environment. At best the system of tree management was ad hoc.

Following 21 February 2014 the Department has conducted thorough reviews and put in place policies that will hopefully prevent further tragedy. Each Principal will conduct a site review of all trees in their school environment every twelve months.

The recommendations by Ms King concerning this issue have all been adopted.

It is acknowledged that that there is no such thing as a completely “safe” tree. Even an apparently sound tree can fail. No system is perfect. What must be balanced is the desirability of providing a landscape within school grounds that provides attractiveness, utility and safety.

Part of this balance can hopefully be met by the system now in place and the regular audits conducted by the Department.

It is noted that the representative for the Department has assured the inquest that Mr Perrau‟s proposal for a five year compliance check by a qualified arborist of all trees will be viewed favourably by the Department.

For this reason I do not propose to make any recommendations.

I make the following formal Findings: Bridget Wright died on 21 February 2014 at the Children’s Hospital at Westmead.

Cause of Death: Multiple injuries Manner of death: Bridget died as a result of a falling tree branch which struck her when she was in the playground at Pitt Town Public School I close this inquest Deputy State Coroner H. Barry Date 20 November 2015

.