A school academy trust has been fined £300,000 after a 19-year-old student died as a result of a ‘series of management failures’.
Owen Garnett, who was described by his family as having “an incredible sense of humour” and who had “everything to live for” died two days after choking on a paper towel at Welcombe Hills School in Stratford-upon-Avon on 9 January 2023.
The teenager was a Sixth Form student at the school, which is for children with special educational needs and part of the Unity Multi Academy Trust (MAT). He had been diagnosed with Pica – a potentially life-threatening eating disorder where sufferers have a compulsion to eat things which have no nutritional value. He had been a student at the school since the age of 11. Despite a near miss incident just days earlier, the school failed to take action to make sure it didn’t happen again.
An investigation by the Health and Safety Executive (HSE) found that none of the staff in Owen’s class team had received any specific training on the management of safety risks associated with Pica.
Before she died, Owen’s grandmother Maureen Garnett provided a statement alongside her husband Cliff.
“After Owen had passed away we never slept, we never ate, all we could do was cry,” they said.
“This lasted for months.
“This was supposed to be a place where Owen was safe and secure and happy.
“Owen had Pica and should have been kept under close supervision at all times and I can’t understand why this didn’t happen.
“We would describe Owen as a unique, lovable, challenging and caring and happy child.
“He will never be forgotten and our family will never get over this.”
The HSE investigation also found that students at the school have individual risk assessments which detail any specific health and safety risks, which relate to them, and the control measures that need to be in place at to protect against that risk. The risk of choking associated with Pica was identified on Owen’s risk assessment and a “named person” was supposed to supervise him to make sure he did not eat anything that could cause him harm.
On 9 January 2023, Owen was out in the playground area with other students during a break from class, unsupervised, and found his way back into school. It took several minutes for his absence to be noticed and when he was found, it was around the side of the building, and he was choking. Emergency services were called, and although they retrieved a ball of paper towel from his throat, he had been without oxygen too long and later died in hospital. Days before, there had been a similar incident with Owen, where he was seen in the playground by a teacher, again choking on blue towel, but Owen managed to clear his airway on his own.
The school failed to ensure that all the safety risks associated with Pica hazards, such as, in Owen’s case, the garden area, or supplies of paper towels, were correctly identified and that the preventive and protective measures including supervision, were organised in such a way as to protect him. They also failed to effectively investigate and respond to the concerns raised by his family.
His foster parents, Jacqueline and Graham Blackwell, said the day Owen died had started out as any other.
“Owen got up and had his breakfast,” they said.
“I can still remember him waiting excitedly for his usual taxi driver to pick him. He gave me a cuddle and then left for school.
“Owen was part of our family, we had made so many adjustments and made so many plans so that he could remain with us indefinitely.
“We had been saving to take him to Florida to swim with dolphins, but this is something he will never get to do. We ended up having to use this money to cover the cost of Owen’s funeral.
“His death has ruined every part of our lives.
“Owen had everything to live for and was such a character and used to love joking and playing about – he had an incredible sense of humour.”
- HSE guidance states that when assessing the health and safety risks to individual students is necessary, educational employers should follow a risk management approach that focuses attention on the real risks; involving employees, students and carers in identifying the individual’s needs and necessary precautions.
Unity MAT, c/o Woodlands School Packington Lane, Coleshill, Birmingham, pleaded guilty to breaching Section 3(1) of the Health and Safety at Work etc. Act 1974. They were fined £300,000 and ordered to pay £10,750 in costs at Coventry Magistrates Court on 18 December 2024.
HSE inspector Rebecca Whiley said: “This tragic incident could have easily been avoided if Owen was being closely supervised, as he should have been.
“The near miss incident a few days before should have raised the alarm with the school and triggered an investigation into how Owen had been able to access the paper towel, and steps could have been taken to prevent it happening again.
“His death resulted from a series of management failures throughout Owen’s time at the Hub, and a failure by the school to act on the concerns raised by his family.
“Our thoughts today are with Owen’s family. He was a young man with a happy life ahead of him. He should have returned home safely to his family after a day at school, but because of the failings by Welcombe Hills School and Unity MAT, he did not.”
This HSE prosecution was brought by HSE enforcement lawyer Arfaq Nabi and paralegal officer Sarah Thomas.
Further information:
- The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We are dedicated to protecting people and places, and helping everyone lead safer and healthier lives.
- More information about the legislation referred to in this case is available.
- Further details on the latest HSE news releases is available.
- HSE does not pass sentences, set guidelines or collect any fines imposed. Relevant sentencing guidelines must be followed unless the court is satisfied that it would be contrary to the interests of justice to do so. The sentencing guidelines for health and safety offences in England and Wales can be found here and for those in Scotland here.
- HSE guidance on supporting pupils with disabilities, special educational needs and additional support needs is available.