A school academy trust has been fined £300,000 after a 19-year-old student died as a result of a ‘series of management failures’.

Owen Garnett died two days after choking on a paper towel at his school. Credit: HSE.
Owen Garnett died two days after choking on a paper towel at Welcombe Hills School in Stratford-upon-Avon on 9 January 2023.
The teenager was a Sixth Form student at the school, which is for children with special educational needs and part of the Unity Multi Academy Trust (MAT).
He had been diagnosed with Pica – a potentially life-threatening eating disorder where sufferers have a compulsion to eat things which have no nutritional value.
He had been a student at the school since the age of 11. Despite a near miss incident days earlier, the school had not taken action to make sure it didn’t happen again.
On 9 January 2023, Owen was out in the playground area with other students during a break from class, unsupervised, and found his way back into school.
It took several minutes for his absence to be noticed and when he was found, it was around the side of the building, and he was choking.
Emergency services were called, and although they retrieved a ball of paper towel from his throat, he had been without oxygen too long and later died in hospital. Days before, there had been a similar incident with Owen, where he was seen in the playground by a teacher, again choking on blue towel, but Owen managed to clear his airway on his own.
No training on Pica
The Health and Safety Executive (HSE) found that none of the staff in Owen’s class team had received any specific training on the management of safety risks associated with Pica.
The HSE also found that students at the school have individual risk assessments which detail any specific health and safety risks, which relate to them, and the control measures that need to be in place at to protect against that risk.
The risk of choking associated with Pica was identified on Owen’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 HSE found that the school had 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. They also failed to effectively investigate and respond to the concerns raised by his family.
Near miss “should have raised the alarm”
Unity MAT, c/o Woodlands School Packington Lane, Coleshill, Birmingham, 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 18 December 2024.
Before she died, Owen’s grandmother Maureen Garnett provided a statement alongside her husband Cliff saying: “After Owen had passed away we never slept, we never ate, all we could do was cry,” they said.
“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.”
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.
“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.”
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