Government failings led to death of 17-year-old student Adriaan Roodt at Mount Ainslie

A coronial inquest has found inadequate supervision and the failure of the ACT Education Directorate to implement sufficient training and risk management policies contributed to the teenager's death.

Adriaan Roodt died after a log fell on him during a school game of capture the flag on Mount Ainslie in October 2018.

The year 10 Campbell High School student was taken to Canberra Hospital where, tragically, he died soon after.

During the physical education trip, Adriaan was hit in the head by a 188kg log he and some of his fellow students lifted during the game.

In findings published on Friday, ACT coroner James Stewart found Adriaan had died from circulatory failure caused by a traumatic brain injury.

He said "the timing and manner of Adriaan's death was tragic and unnecessary".

Since Adriaan's death, the school no longer holds capture the flag at Mount Ainslie and only on school grounds.

The coroner found there was inadequate supervision during the game which was "a failing of the Campbell High School and the [education] directorate, not any of the individual teachers involved".

Mr Stewart criticised the directorate, saying it "failed to correctly administer [its] policies for excursions and activities".

This constituted "a matter of public safety", he found.

Insufficient clarity, training, compliance checking and policies that were difficult for teachers to access all contributed to the boy's death.

"An adequately conducted risk assessment or risk assessment management plan should have resulted in a different outcome for Adriaan," Mr Stewart said.

"That is a reasonable expectation of policy by parents who place their children in the care of the directorate."

"I find that with greater supervision, Adriaan's death was preventable."

The coroner said that without teacher supervision, "the schoolboys became mischievous and misbehaved".

"Adequate supervision should have swiftly resolved this behaviour and ensured a very different outcome," he said.

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The Roodt family has called for ACT Attorney-General Shane Rattenbury to reconsider a decision not to lay charges over the incident.

Adriaan's mother, Sandra Roodt, said in a statement the family was happy with the outcome of the inquest.

"We wanted to ensure a thorough investigation into the circumstances leading to Adriaan's accident," she said.

"We can only hope that these recommendations, when implemented, will prevent another child sustaining an injury."

Among a series of recommendations, Mr Stewart urged professional development for teachers in respect of risk assessment, relevant policies and procedures.

He suggested the Education Directorate take steps to evaluate the success of these recommendations and publish the outcome. The coroner also recommended Mr Rattenbury review work health and safety laws to ensure children and staff are kept safe.

Recommendations sought by the Roodt family were endorsed by the coroner. These included a review into the directorate's policies on physical activities and excursions, and the development of policies to foster ongoing work health and safety training.

In his closing comments, Mr Stewart said members of the family had conducted themselves with poise during the proceedings.

"I can only conclude that the ACT and Yass communities have lost a bright young person with a bright future ahead of him and that Adriaan was quite a man in the making," the coroner said.

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