Relatives of people who have died in workplaces regularly complain about the lack of communication from OHS regulators and other government and legal agencies who are charged with investigating an incident. A recent example of this is Ann Maitland whose daughter, Michelle, died in a gymnastics class in 2009, but Ann Maitland took action and the safety level of gymnastics classes, and many other workplaces, is likely to improve considerably as a result.
Prior to discussing the government’s report into gymnastics safety, it is worth acknowledging the arduous journey that Ann Maitland ( an occasional commenter on this blog) undertook.
In response to complaints by Ann Maitland, the Queensland Department of Justice and Attorney-General engaged conducted an independent review of the actions of Work Health and Safety Queensland (WHSQ) in relation to Michelle Maitland’s death. The review report found that
“A key deficiency highlighted by Mr Byrne was the inadequate communication with Ann Maitland. He further adds that “any similar situation in the future by the creation of the liaison officer position”. In this regard the Investigations Liaison Support Officer position was implemented in January 2011.”
There were several other recommendations from the review for WHSQ to tighten up enforcement procedures. The fact that an independent review was conducted at all is a major win for Ann Maitland and other Queensland families. The fact that such an independent review was required at all should be a matter of great concern.
Details of the original prosecution of Townsville Gymnastics Association Incorporated do not seem to be publicly available but an appeal against the prosecution was lodged and dismissed, as mentioned in the summary of the incident produced by WHSQ. According to the decision on the appeal, the grounds seem to include a questioning of the extent of the hazard, in effect what constituted the “workplace”. The decision says that
“….it was the contention of the Appellant at trial that the “Hazard(s)” particularised by the complaint confined the case to the area covered by the mats at the end of the tumble tramp/tumble track. The Industrial Magistrate rejected that submission and for reasons previously advanced, I considered His Honour to have been correct. It was an additional aspect of the Appellant’s case that the area of exposed concrete flooring whereat Ms Maitland’s head came into contact with the flooring did not constitute a hazard, because a gymnast concluding the tumble tramp/tumble track manoeuvres, would not enter the area of unmatted concrete flooring unless, as in Ms Maitland’s case, the gymnast rebounded. The Industrial Magistrate rejected that contention (materially) observing:
“[12] The particulars are framed in the alternative so the hazard relates to either the concrete floor or the matting at the end of the tumble track. The defendant must address the risk relating to both hazards. The discharge of its obligations with respect to the mats at the end of the tumble track does not eliminate its obligation to address the hazard associated with the concrete floor particularly having regard to the admissions that Ms. Maitland’s activities included ‘recreational gymnastics’ that were not limited to the use of the tumble track.
[13] In saying that I acknowledge the submissions and the evidence that disclosed that the tumble track had been used by the defendant without incident for over fourteen years. If the undertaking of the defendant was limited to the use of the tumble track and if the use of the tumble track ended upon the gymnast landing safely on the crash mats provided, I would accept that the defendant had taken reasonable precautions and exercised proper diligence with respect to the risks associated with the use of the tumble track. However the hazard(s) identified in the particulars should not be interpreted in such a narrow fashion and the defendant has an obligation to ensure that a person who successfully negotiates the tumble track is not injured elsewhere in the workplace. The workplace in this instance clearly includes the rest of the gymnasium and particularly includes the area of concrete floor commencing at the end of the landing area of the tumble track apparatus.”.
In circumstances in which Ms Maitland had rebounded, had entered the unmatted area and had perished, the Industrial Magistrate’s conclusion that a risk existed, is unexceptional.”
The determination of a workplace in this situation should be noted by other businesses that may feel that it is possible to cordon off public areas from work areas, that hazards have a fixed boundary. The original Industrial Magistrate stated that
“….the defendant has an obligation to ensure that a person who successfully negotiates the tumble track is not injured elsewhere in the workplace…”
The Queensland Government undertook an audit of gymnastics facilities as a result of Michelle’s death. The audit report was released in November 2011. Of the premises visited:
“Inspectors issued a total of 37 enforcement notices. Contact with hard surfaces, such as unprotected gymnastics apparatus was the most common notice issue. The next most frequently issued notice was for unaccredited coaches.”
The report says that safety is being managed “relatively well” however it found:
“Improvement is needed in some areas of gymnastics safety including lesson plans, controlling the risk of contact with hard surfaces, documenting equipment maintenance, controlling the risk of manual task injuries and documenting the skill progression of gymnasts.”
The report made nine recommendations for improvement involving
- reviewing the level of training, assistance and monitoring provided to clubs
- researching ” how to link improved safety outcomes in the sport of gymnastics with the funding and non-financial support provided by [Sport and Recreation Services]”.
- reviewing lesson plans so that “coach positioning and key safety controls” are included.
- “…a training needs analysis” should be undertaken.
- “…research and develop methods to assist gymnastics clubs to conduct risk assessments”
- “… review … equipment maintenance policies and procedures with a view to achieving greater compliance…”
- “… research and develop methods to assist gymnastics clubs in managing the risk of manual task injuries in gymnastic coaches.”
- “…review coach knowledge on spotting and provide additional guidance and training where required.”
- “…research the viability of a simple method to document skill progression of gymnasts, including injury management….”
None of these recommendations are extraordinary for any business or association but they do indicate the extent that safety did not seem to be “on-the-radar” for some of the gymnastics industry in Queensland.
The safety spotlight on the Queensland gymnastic sector came from the unnecessary death of a nineteen year old girl. It is too common for a death to be the motivation for change. The government and the gymnastics associations have begun to develop safety procedures that should have been in place a long time ago. It is well-known that gymnasts, dancers, martial arts students and many other athletes can be injured during training exercises. The standard hazard control measures have been mats and spotters usually supported by the equivalent of the Hill Street Blues safety “slogan” of “Let’s be careful out there“.
The Queensland Minister for Education and Industrial Relations, Cameron Dick, said on 4 November 2011 that
“The report also noted that while most clubs are aware of workplace health and safety standards, only 46 per cent allocated enough time or money to meet safety responsibilities.”
Michelle Maitland’s death has shown that the traditional hazard control measures in gymnastics are no longer considered sufficient. Physical and organisational controls require constant review, revision and improvement. If safety is allowed to stagnate, risks increase. Safety in the gymnastics sector in Queensland is improving as a direct result of Ann Maitland’s questions, complaints and lobbying. There should be more Ann Maitlands.
Inadequate communication with family members by a safety regulator? Now there’s a surprise.
That’s an issue faced by families in just about every state around the country. The sad reality is that even when it’s identified and liaison positions are created, chances are within a year or so it will fall by the way side.
Very few family members have the strength and fortitude to fight for better so we have to bless Ann Maitland for digging deep at a time when she should surely have been trying to heal.
This is certainly a tragedy and one that could have and should have been avoided (as is the case in so mnay instances). A more detailed risk assessment would have observed the hazard and associated risk connected to the exposed concrete and therefore protection would be one corrective action to mitigatge such risk. This highlights that when conducting a risk assessment, one must look at it with their eyes wide open.
Kind of reminds me of the tradegy that occured in Qld some years ago that has resulted in the son of the victim becoming a workplace inspector and released a heart felt video emphasing the importance of coming home at the end of the day (I believe it was called “Homecomings” and the main message there was the importance of performing the risk assessment accurately together with coming home the same way you went to work and saying two words at the end of the day…”I’m Home”).