The family of a teenager described as a "ray of sunshine" who died from a school trip incident continues "to struggle with the idea that there was no prosecution" against the Education Directorate as they urge for changes to public schools' safety culture.
Adriaan Roodt was only 17 years old when he his life was cut short during a trip with his fellow Campbell High School students to Mount Ainslie in October 2018.
The coronial inquest into his death came before the ACT Coroner's Court on Tuesday for legal parties' oral submissions.
Counsel assisting the coroner Rebecca Curran told the court that during the physical education trip, Adriaan was hit in the head by a 188-kilogram log that he and some of his fellow students lifted during a game of capture the flag.
Other students with him at the time ran to seek help from teachers, one pulled Adriaan away from the log and another called triple zero.
A registered nurse who was in the area also helped before ambulance arrived about 10-15 minutes after being notified.
The year 10 student, who lived in Yass and was an avid boxer, was taken to the Canberra Hospital but tragically died from circulatory failure from his head injury with treating doctors concluding the injuries were not survivable.
Ms Curran said no formal risk assessment of the activity at the site, which the school used regularly, was undertaken before the decision was made in the morning to hold the game there.
Only a safety briefing at the school gym was held prior to the trip, which involved about 120 year 9 and 10 students, to Remembrance Nature Park at the mountain's base.
Ms Curran said the terrain and natural environment meant it was not possible for teachers - of which there were five - to "have eyes on all students all the time".
"No teacher directly observed the incident which caused Adriaan's injuries although one teacher speaks of hearing a scream," she said.
Safety culture 'a matter to be looked at'
After a two-year investigation, no charges were laid as authorities said there was an insufficient prospect of a conviction.
Jamie Ronald, the lawyer representing the Roodt family, said the safety culture of outdoor activities at the ACT Education Directorate was "a matter to be looked at in this inquest".
"They [family] strongly believes there were serious failures that contributed directly to Adriaan's death and it's necessary that your honour makes an investigation of that death," Mr Ronald said.
He said the family was concerned about the underestimation of dangers posed to students during outdoor activities and that they believed there were failures in design, communication, implementation, training and safety policies related to such activities.
"The family acknowledges some changes already made by the directorate but believe that for a variety of reasons, it's necessary that your honour also report on those matters and the public identification of those failures," Mr Ronald said.
He said that while the school had other outdoor-related risk assessments, they did not include the possibility of a fatal incident and that "there were failings all the way up" in relation to the Mount Ainslie incident.
"There's even some astounding evidence in one interview when a teacher described whether or not there'll be appropriate training ...[the teacher] makes a flippant comment that 'it'd be a boring day'," Mr Ronald said.
"The family continues to struggle with the idea that there was no prosecution in this matter.
"The family wants to see lasting change, they want to see institutions deterred from becoming lax about the safety of children."
He said that the family wanted to let the other children involved in the incident know that none of them intended for Adriaan to be hurt and that they thanked the teachers and emergency workers.
'Terrible' incident a catalyst for reflection
Vanessa Thomas, the lawyer for the territory, paid tribute to Adriaan and his family before outlining how "this terrible" incident and Adriaan's legacy have led to changes.
"[The incident] has been a catalyst for reflection and inquiry as to how the safety of students engage in health and physical activities within public schools in Canberra can be better safeguarded," Ms Thomas said.
"While at same time ensuring that students ... continue to benefit from a wide-ranging and engaging and sometimes challenging health and physical education activities."
Ms Thomas said since Adriaan's death, a taskforce had been established that resulted in a "complete revision to policies and procedures in place at the time of the incident".
She said the directorate welcomes this inquest as another opportunity to gain insight into improvements.
The issues being examined in the inquest include whether the game of capture the flag can be characterised according to one or a combination of terms in the directorate's policy and procedure.
It also includes the appropriateness of any relevant guidance material, supervision of students on the day, appropriate training for teachers and potential recommendations related to public safety matters.
Since Adriaan's death, the school no longer holds capture the flag at Mount Ainslie and only on school grounds.
Earlier in the hearing, Adriaan's mother, Sandra, read out a statement on behalf of the family, describing him as being like "a ray of sunshine brightening up the lives of everybody he had contact with".
As a tribute, photos of Adriaan and his loved ones were also played to the court.
Coroner James Stewart will deliver his findings at a date to be fixed after he receives further written submissions from all parties by late June.
