Local Court New South Wales

• Medium Neutral Citation: Inquest into the deaths of Hannah Taylor and Amelia Catherine McGuiness [2011] NSWLC 13
• Hearing dates: 10-11/02/2011
• Decision date: 08 April 2011
• Jurisdiction: Coronial
• Before: Magistrate van Zuylen

Decision

After a careful consideration of the circumstances surrounding the deaths of Hannah and Amelia, other evidence heard in Court and the written submissions, this Inquest has strongly come to the view that the supervision of school students whilst skiing on school excursions must improve.

• Catchwords: CORONIAL JURISDICTION - deaths of two teenage school students in skiing accidents on school excursions - need for improvement of supervision - recommendations made to the Minister for Education and Training and the Minister for Sport and Recreation
• Category: Principal judgment
• Parties: N/A
• Representation: Sergeant Marc Chaplin (Police Prosecutor assisting the Coroner)
• File Number(s): 18/2009 - Hannah Taylor; 23/2009 - Amelia Catherine McGuiness

JUDGMENT

Report of the Coroner into the deaths of Hannah Taylor and Amelia Catherine McGuiness

1 Hannah Taylor died on 1 August 2009. She was participating in a school ski excursion at Thredbo Ski Resort with fellow students from James Sheahan Catholic High School Orange.

2 Amelia McGuiness died on 27 August 2009. She was skiing at Perisher Ski Resort. Amelia was a student at Barker College, which was conducting a school ski excursion, and she was part of that excursion at the time of her death.

3 Hannah was 16 years of age at the time of her death. She was popular, talented, creative, with an effervescent personality. She had recently played the lead in a school musical production. Her mother described her as a very confident girl, who liked challenging herself - usually with musical and dramatic performances - not physical challenges like skiing. Her athletic ability was fairly average.

4 Amelia was also 16 years of age at the time of her death. She was an excellent skier, who had been skiing since she was 3 years old. She had competed in Interschool competitions for 5 years over all skiing disciplines, achieving podium finishes on numerous occasions. Her family has been involved in the skiing industry for 3 generations, her brothers have ski raced and one of her brothers is a ski instructor. Her family have since set up a Foundation, the 'Amelia McGuiness Australian Snowsports Development Foundation' to raise money for allocation to up and coming skiers aged under 18. Mr Samuel McGuiness, Amelia's father, told the Inquest that $27,000 has already been allocated to young skiers from the Foundation.

5 A decision was made to hold a joint inquest due to a significant similarity; both girls were on school ski excursions.

6 This inquest has not tried to attribute fault or make findings in relation to negligence or breach of duty of care. It devoted a significant amount of time to investigating what recommendations it could make to improve the safety of young people visiting the ski fields on school ski excursions. However, before considering that issue, I shall detail the exact circumstances of the skiing incident that led to each girl's death.

7 Hannah Taylor had travelled down to Jindabyne on Friday 31 July 2009. She travelled with her school group up to Thredbo on Saturday 1 August. She had completed a ski lesson in the morning, then skied for a period of time with her friends, had lunch, and then travelled up the Gunbarrel Express chairlift with three other school friends. Hannah was skiing on a "Blue run", which, on the Thredbo Trail Map is described as a "more difficult run". One of her school friends, Natalie, in her statement says, "The four of us went to Merritts Run but before we got to the top of Merritts, Sophie and Kate took off their skis and started walking back down because they did not want to ski all the way down the slope. Hannah and I continued up the slope (sic) for a short distance and got to the top of our particular run,......Hannah and I started skiing down Merritts. I was in front of Hannah to begin with but we stopped sometime later and talked about skiing down to the kiosk to catch up with other friends. After we decided to do that, Hannah took off in front of me. I noticed shortly afterwards Hannah was going a little faster than usual, she then disappeared from my sight when she went over and down a crest. After a short time I was unable to see where Hannah went. I stopped and had a look for her, but was unable to see where she had got to. I decided to continue down the slope and got to the bottom of the run." This was the last anyone saw of Hannah before she was discovered fatally injured in the trees at the bottom of the inner loop ski run. There were no eyewitnesses of the route she took into the trees. The witness who discovered Hannah in the trees believed he found her at about 1pm. However, ski patrollers, in their statements, have put the time of the incident at 1.30pm. It appears that ski patrollers arrived within minutes of being called, attempted resuscitation, but were unsuccessful. Autopsy examination showed severe head injury and chest injuries consistent with a moderate to high speed collision.

8 Amelia McGuiness had travelled down to Jindabyne on Wednesday 26 August 2009 with approximately 10 other Barker students. Amelia was one of twenty students in the Barker ski team to compete in the 2009 NSW Schools Snowsports Championships hosted by Perisher Blue ski resort from 27 to 30 August. Amelia was picked up by her mother at Jindabyne at 6pm and was one of approximately 10 students who were staying with their families rather than staying in a lodge with the teachers. On 27 August at 1.04pm, Amelia was skiing at Blue Cow resort behind 2 other skiers on the "Chance" run which is ranked as "most difficult" terrain on the resort grading. They were travelling at very high speed. An eyewitness, who was a ski patroller, stated they appeared to be under control. She then appeared to be airborne across the easy way out road. She was airborne before the road and she collided with a tree. Witnesses and ski patrol arrived almost immediately but it appears that Amelia died instantly. In his statement, David Milford, Safety Compliance Manager at Perisher Ski Resort, says, "After examining the witness statements, considering the position of the ski that was in amongst the tree trunks, the marks on the trees, the apparent injuries and the position of the deceased, I am of the opinion that McGuiness either lost control on the run prior to the road or as she has skied onto the road. She has impacted the clump of trees at speed and then travelled between the trunks or been flung around the outside of the clump, coming to rest on the far side of the trees." The Autopsy Report said she suffered severe closed head injuries and limb injuries.

9 Mr Andrew Payne, a teacher from Barker College, was the Ski Team Coordinator for the trip. Mr Payne has been employed by Barker College for 10 years and his responsibilities include PDHPE Teacher, Housemaster, Sportscoach (First XI Cricket and Senior Rugby) and previously Ski Team Coordinator for years 2003 to 2007, although he could not be precise about the exact dates. The team was accompanied by another teacher, Ms Amy Mackay, whom he describes as having a, "basic level of skiing", who has skied a few seasons. Mr Payne has been skiing for 8 to 9 years, he describes his skiing standard as, "Nowhere I can't go". He has mainly snowboarded and agreed that he is supervising skiers on the trip who are a better standard skier than him. Mr Payne does not have any skiing qualifications. Mr Payne had only stepped in as Ski Team Coordinator for this trip at the last moment as the current coordinator had to attend a family funeral, and the school was keen to send someone with as much experience as possible.

10 In his statement and in oral evidence, Mr Payne described his duties whilst on the trip, which included 24 hour supervision of those students staying with him at their lodge, contact and meeting arrangements, attendance at and supervision of racing and competition and assistance should injury or accident occur. When students are not in competition, they are allowed to ski in groups and enjoy the mountain or take lessons. He said that they set a number of rules for this "free skiing " (my term) including staying on patrolled runs, skiing in groups of at least 2, with 3 a preference and ensuring they are in groups before they go off skiing after completing their competition, and the requirement that the students wear a helmet. Mr Payne did not assess the standard of the student skiers before allowing free skiing because he assumed that as they were racing in a competition, they were well above average. Mr Payne did not directly supervise students when they were skiing outside of competition. By that I mean, he did not ski with them or keep them in eyesight.

11 Mr Stephen Hick was the organiser for the James Sheahan Catholic High School ski trip. He has been employed as a teacher there for 23 years, he teaches industrial arts - wood, metal, engineering, automotive, a whole mixture of things. Mr Hick said he had 20 years experience skiing - just weekends, who assessed his ability in the "middle range" who "steered away from black runs". He said he had organised the school ski trip for 20 years. He has no skiing qualifications. Another teacher, Ms Rae Peisley was also on the trip. Mr Hick described her skiing ability as "not as good as mine". He said that Ms Peisley had probably skied 3 or 4 times and was a beginner skier. He could not remember exactly how many students were on the trip but thought up to 20.

12 Mr Hick had arranged the school ski trip with an organisation, Action Learning Initiatives (ALI). In his written statement and in oral evidence, Mr Hick described what happened on the trip, there was a safety talk given on the Friday night on safety in the snow and the "Alpine Responsibility Code". On the bus trip up to the resort, the students were shown a 12 minute "Snowsafe" DVD from ALI. There was a mandatory 2 hour ski lesson on the Saturday morning and the wearing of helmets was compulsory. After their ski lesson, the students were divided into "buddy groups" of 4 and they would ski around in those groups. Mr Hick allowed free skiing in certain areas. Most of the students would stay down the bottom (presumably Friday Flat at Thredbo), skiing on black runs was not allowed and he would meet up with the groups as he was skiing around.

13 Whilst Mr Hick made no formal assessment of Hannah's skiing ability and said that he does receive a little bit of verbal feedback from ski instructors, in his statement and in oral evidence to court, he described Hannah as being "quite a competent skier" and "quite experienced". Mr Hick's assessment of Hannah's skiing ability is contradicted by her father, Mr Robert Taylor. In his statement, he said she had only ever skied for 2 days at Mount Selwyn with him and her 2 brothers in the July school holidays, weeks before her death. Mr Taylor considered his daughter a beginner skier and still learning. A snow sports instructor, Gareth Evans, in his statement dated 2 August 2009, described the lesson he had with Hannah's group. He says the group, "picked up both snow ploughing and gliding plow (sic) very quickly so we progressed to the carpets" (a beginner lift on Friday Flat -my insertion). At the end of the lesson Mr Evans gave the group a progress report and suggested that they practise their turns on the carpet and for those who were confident, progression to the Easy Does It Chair (a ski lift on Friday flat) would be appropriate. Mr Hick was not aware of the ski instructor's advice to his group.

14 In hindsight, it seems quite clear that when Hannah suffered her fatal injury, she was skiing on a run well beyond her ability and experience.

15 As mentioned previously, James Sheahan Catholic High School had arranged the ski trip with a private organisation, Action Learning Initiatives (ALI). The Court heard evidence from Mr Andrew Brown, the managing director. He has been a skier for 20 years and describes himself as a "high level skier". He does not have any skiing qualifications. His organisation arranges winter activities (mainly skiing) for approximately 70 schools for numbers of students from 20 to as many as 180. He did not have any direct involvement in James Sheahan High School's ski holiday. ALI provides accommodation, transport, ski equipment, issues lift tickets, arranges ski lessons with Thredbo Ski School and "facilitates" the holiday. Mr Brown made it clear that his organisation does not supervise skiers whilst they are "free skiing". Mr Brown made the observation that of all the students who were on the ALI programme, 75% would be beginners, 20% would be intermediate and 5% would be advanced.

16 The Court heard evidence from Robert Broadhurst and Keith McReynolds. Mr Broadhurst is a Senior Project Officer with the NSW Department of Sport and Recreation and was a Programme Coordinator at Jindabyne from 1995 to 2001. He is a very experienced skier and snowboarder who has a Certificate 4 in Outdoor Recreation, qualifications in first aid and resuscitation, and conducts staff training. NSW Sport and Recreation provided written information advising that they had in excess of 2500 people participate in their on-snow programs in 2009. In his evidence, Mr Broadhurst estimated that approximately 70% to 74% of the participants in the Jindabyne snow programs were beginner or first timer standard.

17 Mr McReynolds is a Project Officer with the NSW Department of Sport and Recreation. He is a volunteer ski patroller at Perisher, has qualifications and extensive experience as an alpine guide. He is currently the Project Officer for the Duke of Edinburgh outdoor education programme. He is also a very experienced skier. Mr Broadhurst and Mr McReynolds were called to give evidence as to how safety could be improved on the ski slopes for students. The Court thanks them for their attendance and the knowledgeable opinions and insights they provided.

18 The final expert witness called was Mr Adam Hosie. Mr Hosie is the General Manager of Thredbo Snow Sports School. He is an exceptional skier who has twice won a World Synchronised Skiing Championship, two times runner-up in the United States Powder 8 Championships, won the Thredbo Masters Ski Race 3 times, and has the highest level Australian Professional Ski Instructors qualification. He trains and examines ski instructors. Mr Hosie sat in Court for the entire day's evidence and gave his evidence at the end of the day. The Court thanks him for making available his time and providing his expert opinions and knowledge.

19 As part of the Court's preparation for this Inquest, letters were written to a number of organisations inviting them to offer the Inquest practical advice or suggestions on how to make these group activities safer for young people visiting the ski fields. The Court received a number of thoughtful and considered written replies and specifically thanks the following persons and organisations for their contributions:

Frances (Taylor) Gleeson (Hannah's mother)

Sam and Cathy McGuiness (Amelia's parents)

Mr Roderic Kefford Headmaster from Barker College

Mr Andrew Rostron Principal Snowy Mountains Grammar School

The Association of Independent Schools of New South Wales

NSW Sport and Recreation

Mr Peter Brulisauer Chief Executive Officer Perisher

NSW Department of Education and Training

20 A number of written submissions received suggested making the wearing of helmets compulsory for school students. The Inquest did not enquire into the advantages/disadvantages of wearing helmets, but did have tendered to it some information on the issue. In the abstract of their article titled, "How Fast Do Winter Sports Participants Travel on Alpine Slopes," the authors JE Shealy, CF Ettlinger and RF Johnson ( http://www.astm.arg/DIGITAL_LIBRARY/JOURNALS/FAI/PAGES/JAI12092.htm ) measured the speed of some 650 individuals at three different ski resorts in the U.S. during the winter of 2002/2003 on wide, straight, well groomed "blue square" (more difficult) trails and observed an average speed of 44.5 km/h for skiers which was well above the speeds (22.6km/h) used for one helmet testing protocol for recreational snow sports helmets. Also, in this particular study, they found that the average speed for helmet users of 45.8 km/h was significantly higher than those not using a helmet at 41.0 km/h and males ski and snowboard significantly faster than females. The website www.ski-injury.com concludes that there is no conclusive scientific evidence that helmets reduce the risk of death in the event of a high speed collision.

21 There was no evidence to suggest what speed Hannah and Amelia were travelling at. Both were wearing helmets, and quite obviously, the wearing of helmets, in their cases, did not prevent their deaths.

22 A conclusion that can be drawn from the information provided and the deaths of Hannah and Amelia, is that skiers, both inexperienced such as Hannah and experienced like Amelia, regularly travel at speeds much greater than those where helmets will save your life when your head collides at speed with an object like a tree.

23 The Inquest considered the issue of skiing qualifications for teachers taking school ski excursions. It was observed earlier that none of the 4 teachers on the James Sheahan and Barker ski excursions had any skiing qualifications and that one of the two teachers from each school was considered either a "basic" or "beginner" skier. Mr Hosie (General Manager Thredbo Snow Sports) observed that the skiing standard of teachers on school ski excursions was generally quite low. It should be noted that Mr Hosie was not specifically commenting on the skiing standards of Mr Payne or Mr Hick. Mr Hosie also commented that after listening to evidence of how James Sheahan and Barker organised their ski trips, "They were two of the more organised schools" he had seen.

24 Mr Broadhurst and Mr McReynolds (both from NSW Department of Sport and Recreation) advised the Inquest that there are TAFE qualifications of some relevance to skiing. Mr Hosie advised that both Thredbo and Perisher offer an APSI entry level skiing certification. The cost at Thredbo is $720 and for a level 8 skier it would take 3 days and for a level 5 skier it would take 4 weeks. The NSW Department of Education and Training have "Guidelines for Specific Sports and Sports and Physical Activities" at http://www.sports.det.nsw.edu.au/spguide/activities/index.php and more specifically 'Guidelines for Skiing - Snow (Alpine and Nordic)' where they state that, "The leader and/or instructor must have a sound technical background in alpine skiing and be a competent skier." The Inquest observes that it would certainly be desirable for teachers leading ski excursions to have qualifications and/or considerable experience, but Mr Brown (from ALI) pointed out the impracticalities and expense of teachers getting some sort of qualification when 98% of his customers are more than 3 hours and up to 11 hours travel away from the ski resorts. Mr McReynolds also expressed concerns that a requirement for accreditation would be onerous and discourage school based volunteers.

25 The Inquest noted that both Hannah and Amelia were not under any direct teacher/instructor supervision when they died whilst skiing. A considerable amount of time was spent examining whether recommendations could/should be made requiring direct teacher/instructor supervision of students whilst on school ski excursions. For example, the "Staffordshire Guidelines for Ski Course Organisers and Leaders" says that at all times pupils should be in full view of a supervising member of staff whilst on nursery slopes. Also, "A Teacher's Guide to Snowsports" produced by the Snowsport Forum (United Kingdom) says, "It is essential to ensure that if pupils are allowed to ski or snowboard outside their lessons, they do so with a suitably qualified person."

26 The question of direct supervision of students whilst free skiing, and more particularly keeping skiers in eyesight of teachers at all times, was put to each of the teachers called and the expert witnesses who attended. Mr Payne said he was not opposed to students being much more closely supervised. He was quite prepared to implement an arrangement such as keeping students in view at all times and saw it as a good idea. Mr Hick expressed the opinion that you would not be able to run a ski trip and spoke of the practical difficulties involved. Mr Broadhurst thought direct supervision unworkable and impractical. Mr Brown (from ALI) was vehemently opposed to direct supervision of students skiing, whilst outside of lessons, on school ski excursions. Whilst the Court accepts the genuineness of the opinions of those witnesses who spoke of the difficulties of direct supervision of school students skiing, their views must be contrasted with the apparently different attitude taken in the United Kingdom. It is reasonable to assume that the absolute numbers of school students participating in school ski excursions are much greater in the United Kingdom than in New South Wales. Different supervision requirements do not appear to restrict the popularity of United Kingdom school ski excursions. It is also noted that there are formal snowsport awards and qualifications available to teachers and group leaders provided by the National Governing Bodies for snowsport in the United Kingdom.

27 The Court must also take into consideration the observation made by Mr Hosie, and referred to earlier, of the generally low skiing standard of teachers accompanying school ski excursions. An implication of this observation must be that a significant number of teachers are simply unable to properly supervise the students whilst skiing if it were to be made a recommendation that students be within their eyesight at all times. Also, many teachers would not have the ability to assess the skiing standard of those students they are supervising and hence be able to advise or direct students about which ski runs are beyond their ability to ski safely.

28 The one resource definitely available, with experience and qualifications to both teach and supervise students on the ski slopes, are the Ski Schools at each of the ski resorts. Mr Sam McGuiness, Amelia's father, said he is a firm believer in qualified ski instructors teaching your children. Mr Hosie, from Thredbo, said that the availability of instructors is not a problem at his resort, nor would one expect, at other NSW resorts. Mr Brown, from ALI, advised that it is a requirement of the skiing program his organisation offers, for students to have a morning ski lesson with Thredbo Ski School. He advised that if schools were prepared to pay for an afternoon ski lesson, his organisation would arrange it. Of the 70 schools who use his organisation, only 2 opt to arrange afternoon ski lessons.

29 Mr Brown (ALI) estimated the cost of an additional afternoon lesson through his organisation would be approximately $28.00 per day per student. Mr Hosie, from Thredbo Snow Sports School, estimated that the cost for an additional lesson from his ski school would be slightly less than that.

30 The cost, in 2009, of the James Sheahan Catholic High School ski excursion for the weekend was $480.00 per student but due to insufficient numbers, there was an additional fee of $45.00, which the students volunteered to pay to avoid cancellation. Whilst the Court acknowledges that ski excursions are expensive and cost must be an important factor to families, it is not unreasonable to assume that when 75% of students, on average, are beginners, families would be prepared to pay an extra (estimated) $20.00 to $28.00 per day, for a second afternoon ski lesson, to improve the tuition, safety and supervision of their children on a school ski excursion.

31 Whilst snow sports in the alpine environment carry an element of risk as shown by the tragic deaths of Hannah and Amelia, this Inquiry has no desire to discourage school ski excursions. Skiing is a popular, fun and exhilarating sport. Skiing and snowboarding offer many distinct benefits to those taking part. Valuable contributions are made to the acquisition of physical skill and knowledge, personal and social development, environmental awareness and the health of the individual, contributing to the uptake of an active lifestyle. Skiing and snowboarding are not difficult sports to learn and rely on technique rather than strength and fitness.

32 The Inquest has concentrated on how ski and snowboarding supervision can be improved on the slopes and, to limit the scope of the inquest, has not inquired into many other potential safety issues of students whilst on school ski excursions.

33 The Inquest has also been mindful of the very different types of school ski excursions that exist. Hannah Taylor's school ski excursion was of a very different nature to the ski excursion Amelia McGuiness was on. Another type of school ski excursion was detailed in a letter received from Mr Andrew Rostron, Principal of Snowy Mountains Grammar School, whose school sends about 180 students onto the ski slopes every Wednesday in Term 3, as part of their sports program and enter teams into competitions on weekends.

34 After a careful consideration of the circumstances surrounding the deaths of Hannah and Amelia, other evidence heard in Court and the written submissions, this Inquest has strongly come to the view that the supervision of school students whilst skiing on school excursions must improve.

35 Finally, this Inquest realises that tragedies and injuries, whilst rare, are inevitable in snowsports, it hopes that the adoption of the following recommendations reduce the likelihood of deaths of young persons as talented and loved as Hannah Taylor and Amelia McGuiness.

RECOMMENDATIONS

To the Minister for Education and Training and the Minister for Sport and Recreation:

(1) The Coroner recommends that where possible all students on school ski excursions be closely and directly supervised by either teachers capable of skiing with them on the ski run they are skiing on, or by qualified ski instructors. (Please note the qualification in Recommendation 5)

(2) The Coroner recommends all students on school ski excursions must have ski lessons each morning of every ski day. (Please note the qualifications in Recommendations 4 and 5)

(3) The Coroner recommends schools encourage students of beginner and intermediate level to have a second ski lesson in the afternoon.

(4) The Coroner recommends that students only be excused from ski lessons if qualified instructors or appropriately qualified and experienced teachers assess that the students are capable of skiing safely and in control on the ski runs where they are allowed to ski.

(5) If schools conducting ski excursions take the view that students may ski without close and direct supervision by teachers or appropriately qualified persons, the Coroner recommends the following requirements be adhered to;

(a) Written and informed consent must be given by their parents,

(b) The students can only ski on runs where they have been previously taken by ski instructors or other qualified supervisors,

(c) The students ski in groups of at least 4 and NEVER leave a fellow student alone

(d) The students ski within the ski resort boundaries

(e) The students be told to always stay in control and be able to stop and avoid other people or objects.

(6) The Coroner recommends that the Minister for NSW Department of Education and Training consider incorporating the preceding recommendations into their "Guidelines for Specific Sports and Physical Activities Skiing - Snow (Alpine and Nordic)" at: http://www.sports.det.nsw.edu.au/spguide/activities/skiing/skiing.php

(7) The Inquest recommends that a copy of these Recommendations, along with the NSW Department of Education and Training Guidelines for Specific Sports and Physical Activities Skiing - (Alpine and Nordic) and the Alpine Responsibility Code be sent to:

The NSW Department of Education and Training

NSW Sport and Recreation

The Catholic Education Office

The Association of Independent Schools of NSW

Perisher Resort

Thredbo Resort

Selwyn Snowfields

Action Learning Initiatives Pty Ltd

For these organisations to forward them on to all schools who they know conduct ski excursions.

Decision last updated: 23 May 2011