Christopher Sears

PFD Report All Responded Ref: 2016-0212
Date of Report 25 May 2016
Coroner Karen Henderson
Coroner Area Surrey
Response Deadline est. 20 July 2016
All 2 responses received · Deadline: 20 Jul 2016
Response Status
Responses 2 of 3
56-Day Deadline 20 Jul 2016
All responses received
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Coroners Concerns
During course of the inquest the evidence revealed matters giving rise for concern. In my opinion there is a risk that future death will occur unless action is taken: There is no requirement for bus companies tendering for contracts from Local Authorities to transport pupilslstudents to ensure all their drivers have undergone training in Basic Life Support: There is no requirement for drivers transporting pupilslstudents to hold a Basic Life Support qualification 3, No protocols were in place to assist a driver as to what to do in an emergency situation whilst driving bus including the need to call the emergency services at the earliest opportunity: The school were unable to inform the bus company concerned without a formal diagnosis and to put protective measures in place Basic Life Support training is not taught as a matter of course to young adults in secondary education is not part of the national curriculum
Responses
Department for Transport
Response received
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From the Parliamentary Under Secretary of State Andrew Jones MP Department Greal Minster House for Transport 33 Horseferry Road London SWIP 4DR Tel: 0300 3303000 Dr Karen Henderson E-Mail: clo Sarah Church, PA to HM Coroner for Surrey Web slte: WWw.gov.ukldft HM Coroner's Court Station Approach Our Ref: MC/166456 Woking, Surrey GU22 TAP 3 0 Aug 2016 Decs N Heulos _ Thank you for your Regulation 28 report made under the Coroners (Investigations) Regulations 2013 into the death of Christopher Sears on a school bus in November 2014. This letter details the Department's response as required by regulation 29 of the above Regulations. The Department has carefully considered the report, and the potential actions that it considers it could take to ensure that the tragic circumstances that your report describes are not repeated. This letter sets out our responses to your first three matters of concern, which are each matters in which both the Department for Education (DfE) and the Department for Transport (DfT) have involvement: understand that the Department for Education will be responding to you separately, including on the final two issues that are education-specific. DfE provides guidance to Local Authorities on the provision of home to school transport; which can be found at: https IIwWW Yov Uklgovernment/publications/home-to-school-travel-and_ transport-guidance At paragraph 44, the guidance notes:
44. AIl local authorities should ensure that all drivers and escorts taking pupils to and from school and related services have undertaken appropriate training, and that this is kept up to date. It is also considered good practice for those responsible for planning and managing school transport to have undertaken appropriate equality training: This training could consist of (but is not restricted to):

an awareness of different types of disability including hidden disabilities; an awareness of what constitutes discrimination; training in the necessary skills to recognise, support and manage pupils with different types of disabilities, including hidden disabilities and certain behaviour that may be associated with such disabilities; training in the skills necessary to communicate appropriately with with all types of different disabilities, including the hidden disabilities; and training in the implementation of health care protocols to cover emergency procedures. The Department; as a responsible public authority, fully supports DfE's intention, as expressed above, that Local Authorities should ensure that school bus drivers have training in basic life support skills: understand that DfE intends to consult on a revised version of the school transport guidance in autumn: Additionally, professional bus drivers are required to hold a Driver's Certificate of Professional Competence (Driver CPC): After an initial qualification, it requires that the holder undertakes 35 hours of periodic training every 5 years to keep the qualification valid, Training providers offer a range of approved courses within a set syllabus, which includes: "Section 3.5: the Ability to assess emergency situations. This includes: Behaviour in an emergency situation: assessment of the situation, avoiding complications of an accident, summoning assistance; assisting casualties and giving first aid, reaction in the event of fire, evacuation of occupants of a lorrylbus passengers, ensuring the safety of all passengers, reaction in the event of aggression; basic principles for the drafting of an accident report: [See https:Iwww 9ov uklgovernmentlpublicationsldriver-cpc-syllabus] The Driver CPC is purposely designed to be flexible in its application no specific part of the periodic training syllabus is mandatory, and the Department believes that this is important to ensure that training can be focussed on every individual's specific training needs: In 2014/15 275,900 drivers chose to undertake training courses that taught them either basic or more advanced first aid techniques; while that total includes both bus and HGV drivers, it nevertheless suggests strong take-up. pupils

Considering both those positions, it is not proposed to make basic life support training a mandatory requirement forbus drivers. have however asked the Driver and Vehicle Standards Agency (DVSA), who are responsible for the Driver CPC , to undertake some promotional activity to ensure that awareness of the relevance of basic life support training as of an individual bus driver's development needs is as high as it should be. This will be undertaken through the DVSA's regular communication and stakeholder engagement routes, but particularly through targeted communications and social media activity around the 10 September 2016. This date is both World First Aid and the 10th anniversary of the implementation of the Driver CPC in UK law; providing an ideal opportunity to reinforce how important basic life support training can be for a driver carrying, in particular, children or vulnerable individuals. Further to this, Department for Transport officials will, through their ongoing engagement with bus industry and local authority stakeholders, take opportunities to raise the profile of this issue. would also add that although there is no specific requirement in health and safety at work legislation for provision of first aid to non-employees (e.g: pupils), in its on-line guidance the Health and Safety Executive (HSE) nevertheless strongly encourages employers to consider non-employees when carrying out their first-aid needs assessment and to make provision for them: As a responsible public authority the Department fully appreciates that the safety of children on the way to and from school on provided transport is of fundamental importance. In this respect the Department is of the view that DfE's guidance to Local Authorities on home to school transport is an appropriate mechanism for achieving the appropriate and necessary level of safety: This is bolstered by the forthcoming consultation which provides an important opportunity to consider and review whether the guidance's expectations can be strengthened. hope that DfTIDVSA supporting promotion of the importance of basic life support training as part of considering a school bus driver's Driver CPC training needs will further strengthen take up of relevant courses_ Yows Sncch) Awte Jne ANDREW JONES MP part Day,
Department for Education
Response received
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Thol FOR Lord Nash Parliamentary Under Secretary of State for the School System Sanctuary Buildings Great Smith Street Westminster London SWP 3BT tel: 0370 000 2288 wwweducation gov uk/help/contactus Dr. Karen Henderson HM Coroner for Surrey HM Coroner's Court Station Approach Woking Surrey GU22 7AP 40 August 2016 024 Thank you for your report into the tragic circumstances surrounding the death of Christopher Sears in November 2014 whilst travelling on a school bus_ am grateful to you for drawing this terrible incident to my attention and have carefully considered the matters of concerns raised in your report; and what action might take to prevent future deaths: concern that LA contractual arrangements do not require tendering bus companies to ensure that their drivers are qualified in basic life support skills is a matter for the Department for Transport (DfT), and we understand that Andrew Jones is replying separately to you on this issue. The Department for Education (DfE) provides advice to LAs on the provision of school transport; which falls within my remit of responsibilities, (this can be found at https:IIwwW uklgovernmentlpublications/home-to-school-travel-and-transport_ quidance): This advises that all local authorities should ensure that all drivers and escorts taking pupils to and from school and related services have undertaken appropriate training, and that this is kept up to date _ This training includes "training in the implementation of health care protocols to cover emergency procedures". It is our intention that LAs should ensure that school bus drivers and escorts have training in basic life support skills and in the implementation of emergency protocols (your third 'Matter of Concern') . We intend to consult on revised version of the guidance on school transport in the autumn: Subject to any responses received in response to this consultation, we will consider whether we should further clarify both the description of the training that drivers should undertake and our expectation that training for bus drivers and escorts should include basic life support training alongside the implementation of healthcare protocols, including emergency protocols. DEPARTNENT Education Your YOV.

On your concern that the school did not; as a result of no medical diagnosis, have medical plan in place; we have already introduced a new duty on governing bodies to support pupils with medical conditions. This was introduced by Section 100 of the Children and Families Act 2014 which came into force on September 2014. Our aim is to give parents confidence that the right support and systems will be put in place to ensure that pupils receive the support need: This is a clear signal to schools that supporting pupils medical conditions is an important issue and will help them to meet their Iegal responsibilities_ The statutory guidance came into force alongside the new duty on September 2014 and is available at https IIwWW Gov Uk/government/publicationslsupporting: pupils-at-school-with-medical-conditions 3. The guidance sets out our minimum expectations of schools, and covers the preparation implementation of school policies for supporting pupils with medical conditions and the use of individual care plans. Schools must have a 'supporting pupils with medical conditions' policy: The governing board should ensure that policies, plans, procedures and systems are properly and effectively implemented: We also advise that schools do not have to wait for a formal diagnosis before providing support to pupils. In cases where pupils medical condition is unclear; or where there is a difference of opinion, judgements will be needed about what support to provide based on the available evidence This would normally involve some form of medical evidence and consultation with parents. The guidance outlines an expectation that school staff; healthcare professionals and parents should work together to agree the type and level of support a child needs when are in school to effectively manage their medical condition: This would usually be recorded in a pupil's individual healthcare plan: It also raises the possibility that LAs may need to be informed, given their responsibility for providing home to school transport: We believe this provides the right level of guidance to schools to ensure that effective healthcare plans are put in place; whilst allowing the flexibility they need when handling an individual pupil's needs. We will, however; ensure that there is a reference to this advice within our guidance on home to school transport so that LAs are aware of the responsibilities of schools in drawing up such plans Finally, on your concern that basic life support training is not taught as a matter of course to young adults, whilst schools are not under a statutory duty to provide emergency life skills teaching; many do teach it as part of personal, social, health and economic (PSHE) education. We do not prescribe which topics schools should teach in PSHE and instead they use their professional judgement to teach bespoke topics to meet the local needs of their pupiis. Having said that; topics for teaching can be wide-ranging and can include first aid and staying healthy. Many schools work with expert organisations, such as the Red Cross and St John Ambulance who provide learning materials, tool- kits and targeted resources and carry-out school visits and life-saving skills demonstrations and events. The Government has promoted the use of these tool- kits and learning resources to schools. Additionally the Government has demonstrated its commitment in this area by: they with and they

Promoting a programme of study that teaches young people to recognise and follow health and safety procedures and how to use emergency and basic first aid, Providing E254,911 in funding for St John Ambulance to support first-aid training for 31,500 pupils and 600 school first aid champions. Support our policy of encouraging schools to purchase defibrillators as part of their first-aid equipment by setting up a scheme so can buy defibrillators at a reduced We believe this range of measures is sufficient to improve awareness of and to support the training of pupils in first aid and emergency medical situations_ are appropriate and proportionate and in line with schools determine their own local needs and priorities_ Overall; believe that the proposed changes to our guidance on home to school transport, together with the revised advice already issued to schools about supporting pupils with medical conditions, and our continued commitment to promoting training in basic like support skills will help to increase further the safety of pupils travelling to and from school. therefore trust you will be reassured that the Government is playing its full part in learning the lessons from Christopher's tragic death and that his family, friends and others affected can take some consolation our efforts to ensure that such rare but terrible incidents are less likely to occur in future. JOHN NASH how they price . They letting from
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation: Bus Company, Surrey County Council, Department of Transport and Department of Education have the power to take such action. being being the and
Report Sections
Investigation and Inquest
On 1gh November 2014 commenced an investigation into the death of Christopher James B Sears. The investigation concluded at the end of the inquest on 23rd March 2016. The medical cause of death given was: Ia. Epileptic seizure My narrative conclusion was: Natural causes
Circumstances of the Death
Christopher was a 13 year old who had an intermittent history of epileptic type seizures with four such events over the previous five years: He had a seizure type episode in 2012 and was referred and assessed by consultant paediatrician with an interest in Neurology: Although no formal diagnosis was made and no treatment instituted, Christopher and his mother were given advice relating to protective measures to take in case of a further event: also heard evidence that as there was no formal diagnosis it was not possible for the school that Christopher attended to have been put on notice with regards to the possibility of epilepsy or steps to be put in place to protect Christopher; including alerting the bus company responsible for transporting students. On the 13/h November 2014 Christopher had another seizure like event on his way home on the school bus after complaining of cluster headache earlier in the morning before school The bus driver was alerted by a friend of Christopher's that Christopher had had a 'seizure' , The bus driver was at a junction and so drove for a short distance to safely stop the bus_ He went to assess Christopher and gave evidence that at this time Christopher was unresponsive and breathing heavily in his seat. The bus driver did not assist Christopher nor did he contact the emergency services He returned to the driver's seat and drove on to the next bus stop where he allowed the other pupils on the bus to disembark: At this point he returned to see Christopher who was still unresponsive and slumped over in his seat: The bus driver left Christopher and alighted from the bus and at that point made a phone call to the emergency services in which he commented to them that Christopher was still breathing and had a pulse although heard evidence from the bus driver that he did not check the pulse_ Before the emergency services attended Christopher's mother arrived having been alerted by the mother of a fellow pupil on the bus_ On seeing Christopher slumped in his seat on the bus on his own she believed that he was already dead: On advice of the ambulance services the bus driver removed Christopher from the bus and an off duty policeman commenced cardiopulmonary resuscitation until the ambulance crew arrived. The resuscitation continued throughout the journey to theRoyal Surrey County Hospital and also within the hospital boy without success and although accepted the evidence that Christopher had more likely than not died on the bus confirmed death was at time all resuscitative measures had proven futile on 13th November 2014. A post mortem was undertaken which was inconclusive but having heard all the evidence accepted the cause of death was more likely than not to be as a consequence of an epileptic seizure which may cause sudden death in its own right but it could not be excluded that postural asphyxia arising from poor positioning after the seizure may have contributed to Christopher's death: Ialso heard evidence that a minimum of ten minutes had elapsed from the time the bus driver had been alerted to Christopher's condition and a 999 call made by him_ No explanation was forthcoming as to the reason for the delay. heard evidence from the emergency services that the earlier they are called the greater likelihood of survival as would also be the case if basic life support measures such as adopting the recovery position were instituted as soon as it was known that someone was unresponsive_ made no finding of fact as to whether this would have changed the outcome with regard to Christopher on the grounds that there was insufficient evidence but commented that it would have been ideal if the emergency services had been called earlier when it was clear Christopher was unresponsive and BLS measures had been understood and instituted. also heard evidence from the police that other than a moral duty to assist there was no legal responsibility or duty of care for a bus driver to undertake resuscitation or assist someone who was unwell. also heard that there was no requirement for drivers to hold qualifications in Basic Life Support techniques_ Nor was there any requirement from private bus companies to teach basic life support techniques to their drivers before tendering for contracts from Surrey County Council locally and nationally despite being the only responsible adult transporting pupils_ This is in the face of it an accepted and mandatory requirement in some European and International countries. also heard evidence from Christopher's mother that the school were not in a position to institute any individual care of a student without a firm diagnosis and therefore it was not possible to alert the bus company of any possible concerns relating to any particular studentlpupil:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.