Accident Reporting and Near Miss

School leaders and service managers need to ensure there is a reporting system in place which captures accidents, incidents and near misses.  Voluntary Controlled/Community Schools, and Kent County Council (KCC) business services should be using KCC’s online reporting form.  Investigations must be undertaken for near misses (and other incidents when necessary) to prevent a similar type of incident from occurring.  The following case study highlights the importance of reporting and investigating a near miss to ensure there is not a re occurrence that may result in injury, harm or tragic circumstances.

A special educational needs Academy has been fined after a 19-year-old student died as a result of a ‘series of management failures.’  The student had been diagnosed with Pica – a potentially life-threatening eating disorder where sufferers have a compulsion to eat things which have no nutritional value.  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 the student’s class team had received any specific training on the management of safety risks associated with Pica.
• The risk of choking associated with Pica was identified on the student’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.

However, supervision was not in place when the student was out in the playground during a break from class and found his way back into school.  It took several minutes for their absence to be noticed and when found they were choking on a paper towel which was eventually removed by Emergency Services. The student had been without oxygen too long and later died in hospital. Days before, there had been a similar incident where the student was seen in the playground again choking on a blue towel, and the student managed to clear their own airway.

HSE guidance states that when assessing the health and safety risks to individual students is necessary, school leaders and service managers 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.

The HSE inspector stated “this tragic incident could have easily been avoided if the student 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 the student had been able to access the paper towel, and steps could have been taken to prevent it happening again.

For health and safety support or advice contact the Health and Safety Team

Advice Line: 03000 418456 or email: healthandsafety@kent.gov.uk