Warwickshire school fined £300,000 after ‘management failures’ led to death of student
Owen Garnett, 19, died after choking on a paper towel at Welcombe Hills School
Last updated 20th Dec 2024
A Warwickshire school academy for children with special needs has been fined £300,000 after a “series of management failures” led to the accidental death of a student.
Owen Garnett, 19, died two days after choking on a paper towel at Welcombe Hills School in Stratford-upon-Avon, on January 9 2023.
The teenager, who was a Sixth Form student at the special educational needs school, had been diagnosed with Pica – a potentially life-threatening disorder where sufferers compulsively swallow non-food substances, putting themselves at risk of poisoning and choking.
An investigation by the Health and Safety Executive (HSE) revealed that Mr Garnett had been left unsupervised during break from class when the fatal accident took place – only days after a similar incident in which the teenager was seen choking on paper towel.
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.”
The HSE investigation found that none of the staff in Mr Garnett’s class team at Welcombe Hills School, which is part of the Unity Multi Academy Trust (MAT), had received any specific training on the management of safety risks associated with Pica.
Yet, students at the school have individual risk assessments that detail the specific health and safety risks relating to them, with the measures needed to protect against those risks.
The risk of choking associated with Pica was identified on Mr Garnett’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, the investigation revealed.
But on January 9 2023, Mr Garnett was out in the playground area with other students and was able to make his way back into school on his own.
It took several minutes for his absence to be noticed and he was already choking when he was found around the side of the school building.
Emergency services were called and, although they retrieved a ball of paper towel from his throat, Mr Garnett had been without oxygen too long and died in hospital.
Mr Garnett’s foster parents Jacqueline and Graham Blackwell said Mr Garnett’s death had “ruined every part of our lives”.
A spokesperson for HSE said: “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.”
Ms Whiley added: “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.”
Unity MAT 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 Wednesday.
Following the hearing, Mr and Mrs Blackwell said: “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.
“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.”
Before she died, Mr Garnett’s grandmother Maureen Garnett provided a statement alongside her husband Cliff, in which she said Mr Garnett was a “unique, caring, and happy child”.
She said: “After Owen had passed away we never slept, we never ate, all we could do was cry.
“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.
“He will never be forgotten and our family will never get over this.”
Unity Mat academy trust have released a statement saying their thoughts remain with Owen's family, and they pledge to honour Owen's memory by creating a safer environment for all.
It wrote: "It is with profound sadness that the Trust extends its deepest condolences and sincere apology for the desperately sad death of Owen. Our hearts go out to Owen's family and friends during this incredibly difficult time.
"In the aftermath of this tragic event, we have striven to ensure that lessons are learned and the learning implemented to guarantee the safest environment for young vulnerable people like Owen to live, learn, and thrive. Our commitment is to ensure a better, safer future for all our students.
"To prevent such a tragic outcome from happening again, The Trust fully and unreservedly accepts that more could and should have been done. With this in mind, a number of measures have been put in place to ensure that no other family goes through what Owen’s family has endured."
These measures include:
• Comprehensive reviews of our safety protocols and procedures.
• Enhanced training for staff to better identify and address potential risks.
• Ongoing support and resources for students to ensure their well-being.
It continued: "We are dedicated to making our schools a safe haven for all children and will continue to work tirelessly to uphold this commitment."