Coroner warns all schools following Opotiki College death

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Opotiki College

A coroner has ordered that his report into the death of a teen who fell through the roof of Opotiki College last year be distributed to all New Zealand state-funded schools.

Coroner Gordon Matenga expressed concern in his report that the college did not comply with a Ministry of Education request to better secure the skylight through which the teen fell, following his death.

Sixteen-year-old Te Hawiki Kiri Te Amo, who was from Christchurch, was visiting his father in Opotiki when he died in October last year.

He and his cousin, Hoani Abraham, who was injured in the fall, decided to climb on to the roof of the buildings. With them were Hoani’s brother, Te Poho Te Amo.

The report states that police evidence indicates the young men climbed the fire escape accessing the roof of a building adjoining the library. From here the young men climbed along the roof line and then on to the library roof to the skylight.

Coroner Matenga said this evidence contrasted with the way in which principal Susan Impey suggested that the young men gained access.

Mrs Impey stated in her response: “There is no direct access to the roof from the ground and we believe access was gained by scaling a concrete wall.”

Opinions of the police officers who had attended, as well as those of Lionel Merriman, the school caretaker at the time, and photographs had supported the statement made by Te Poho, the coroner said in his report.

“The photographs show the fire escape stairs and the access it provides to the roof. I conclude … that the young men gained access to the roof and skylight via the fire escape and not by scaling a concrete wall as suggested.”

The boys were kicking the skylight when it broke and Hawiki landed on the concrete floor of the library eight metres below. Hoani landed on his back, breaking his leg and suffering other minor injuries.

Te Poho ran to a nearby house to raise the alarm while caretake Lionel Merriman received a phone alert about the alarm at the college being triggered.

In the fall, Hawiki suffered a head injury, from which he died the following day in Waikato Hospital.

Coroner Matenga writes that during his inquiry, he became aware of the death of eight-year-old Justin Reid of Palmerston North, which had taken place about one year earlier. Justin had died when he fell through a section of polycarbonate roofing over a walkway between two classrooms at a primary school.

Following Justin’s death, Coroner Peter Ryan had made a recommendation to the Ministry of Education that it consider the appropriateness of utilising roofing material on any structure on school grounds which may shatter or break if walked upon; and if such roofing material is to be utilised, then what measures can be implemented to mitigate the risk of young people falling through those roofs.

Coroner Matenga writes that given the similarities of the circumstances of the death of Justin Read with that of Hawiki’s, he notified Ministry of Education, the Opotiki College Board of Trustees, and Hawiki’s family of his intention to consider reinforcing Coroner Ryan’s recommendation.

“Esther Corlett [Hawiki’s mother] agreed that the recommendation of Coroner Ryan should be reinforced, submitting that security measures should have been enforced earlier,” coroner Matenga writes.

“Ms Corlett also noted that Opotiki College had replaced the library skylight with similar materials as had been there previously.”

Mrs Impey had advised that after consultation with ministry property personnel, it was determined the “satellite dish would be removed and replace the skylight.

Mrs Impey noted: “We engaged a local engineering firm to assess all skylights in the school as the ministry request that we look at the viability of putting up metal grills on the interior. The response was that installation would not be possible as there was no structural framing for the grill to be attached to. I reported this to Ministry of Education property personnel.”

“However, the Court was not told whether the translucent plastic sheeting used in the re-installation was rated as trafficable or if netting was installed, as per the ministry’s guidance,” coroner Matenga writes. “I proceed on the basis that the sheeting was not rated as trafficable and netting was not installed.”

In her letter to the court, Secretary for Education Iona Holsted said: “It is the responsibility of the school’s board of trustees to provide a safe physical environment for their students and we support them in this. The ministry website contains guidance on suitable school roofing materials. This is consistent with Building Code requirements which, since 2006 have required all translucent sheeting within new roofing to include safety mesh to mitigate falling risks.

“Following Justin’s death, we updated this guidance to better assist boards to identify and manage safety risks. Our guidance maintains that ‘if non-trafficable roofing sheets are to be used, these must be laid over safety netting of mesh that is strong enough to hold the weight of an adult.”

Coroner Matenga writes that he was surprised to be advised by Mrs Impey that the decision was to reinstall the skylight without modifications and that all skylights in the school would not be modified as per the ministry’s guidance.

“While I accept that installation of ministry compliant skylights may not have been possible for the lack of structural support, and the availability of funding at the time, funding is now available. Opotiki College Board of Trustees chose to use their capital funding to complete other works. These works include some re-roofing of the gym and a change of pitch to this roof to minimise access by climbing, and removal of the satellite dish. More work is planned but no details have been provided,” he writes.

“Although the issue was not addressed by Susan Impey, the college could have removed the skylight completely, obviating the need for structural strengthening.

“Making roofing safe is a priority area and I expect this to lead to the replacement of potentially unsafe historic roofing material across the school portfolio.

“That this incident did not lead to the replacement of unsafe historic roofing material is a concern.”

“It is also concerning that although the ministry provides guidance to school boards of trustees, there is no obligation on the board to follow such guidance.”

Coroner Matenga recommend in his report that the Opotiki College Board of Trustees either remove the skylight in the roof of the Discovery Centre Building, or otherwise comply with the Ministry of Education guidance.

“I direct that a copy of this finding be distributed to all state-funded schools in New Zealand.”

Mrs Impey and Opotiki College Board of Trustees chairwoman Catriona White issued a joint statement following the release today of the coroner’s report.

“Kiri-Te-Amo died as a result of being on a high roof of one of the school buildings, He gained access to this roof via a fire escape on another building. This was a tragic and traumatic accident for the whanau and although Kiri-Te-Amo was not a student at the College, we were very saddened by the accident and the loss of a young life. Immediately after the incident we contacted the Ministry of Education and met with their personnel regarding mediation action. The school will continue to work with the Ministry of Education in relation to the Coroner’s recommendations regarding building materials for all skylights in the school.”