8 Nov 2023 Owen Paul Garnett · Prevention of Future Deaths report Warwickshire
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Concerns raised 6 Lack of staff guidance on identifying health and safety concerns View source Failure to act on carers’ health and safety concerns View source Lack of clarity about the timing and responsibility for reviewing plan implementation View source Retrospective feedback on prioritising supervision View source Lack of arrangements for carers to participate in and challenge the concerns process View source Unclear circumstances for deviating from planned supervision View source See 3 more concerns
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AI-generated summary
Owen Paul Garnett · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Owen Garnett, a 19-year-old student with severe learning difficulty, swallowing problems and Pica, died after choking on a significant amount of blue paper towel while unsupervised at school. The principal concerns were that carers’ repeated concerns were not acted on, that required supervision was not provided despite the risk assessment, and that the school’s subsequent action plan lacked clear guidance and oversight.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Unity Multi Academy Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff guidance on identifying health and safety concerns
Wider context from the report “1. The evidence showed that the concerns of Owen’s carers were not acted on. Evidence was given that had the school seen the photographs they would have been more likely to have reacted to the information, but less weight was placed on an oral report by carers. The new plan seems to recognise that carers’ concerns should be acted upon by recording as a near miss incident any health and safety concerns and these should be reviewed. It appears that the decision to regard any such concerns as relating to health and safety and then record the concerns can be made at class staff level. There is no guidance as to what should or should not be regarded as a health and safety concerns by staff. There is no guidance as to how carers will be assisted to participate in this process or what steps can be taken by carers who feel their concerns have been disregarded.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Unity Multi Academy Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on carers’ health and safety concerns
Wider context from the report “1. The evidence showed that the concerns of Owen’s carers were not acted on . Evidence was given that had the school seen the photographs they would have been more likely to have reacted to the information, but less weight was placed on an oral report by carers . The new plan seems to recognise that carers’ concerns should be acted upon by recording as a near miss incident any health and safety concerns and these should be reviewed. It appears that the decision to regard any such concerns as relating to health and safety and then record the concerns can be made at class staff level. There is no guidance as to what should or should not be regarded as a health and safety concerns by staff. There is no guidance as to how carers will be assisted to participate in this process or what steps can be taken by carers who feel their concerns have been disregarded.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Unity Multi Academy Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about the timing and responsibility for reviewing plan implementation
Wider context from the report “3. The Health and Safety Inspector present at the inquest indicated that the Inspectorate had not had the opportunity to review the plan and would be considering whether to participate further by reviewing the implementation of the plan. However, as the relevant inspector could not be present, it was unclear when the plan could be reviewed and by whom .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Unity Multi Academy Trust; that does not assign responsibility.
PFD Monitor interpretation Retrospective feedback on prioritising supervision
Wider context from the report “2. Had Owen been supervised as envisaged in his risk assessment, he would not have been able to consume the significant quantities of blue paper towel found in his mouth and throat. The class teachers’ evidence was that after her initial training, the process of advice on prioritising of supervision was retrospective in that she only received feedback on events that had already occurred . The current plan appears to permit the class teacher to deviate from the planned supervision and prioritising of supervision in circumstances that are not made clear.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Unity Multi Academy Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of arrangements for carers to participate in and challenge the concerns process
Wider context from the report “1. The evidence showed that the concerns of Owen’s carers were not acted on. Evidence was given that had the school seen the photographs they would have been more likely to have reacted to the information, but less weight was placed on an oral report by carers. The new plan seems to recognise that carers’ concerns should be acted upon by recording as a near miss incident any health and safety concerns and these should be reviewed. It appears that the decision to regard any such concerns as relating to health and safety and then record the concerns can be made at class staff level. There is no guidance as to what should or should not be regarded as a health and safety concerns by staff. There is no guidance as to how carers will be assisted to participate in this process or what steps can be taken by carers who feel their concerns have been disregarded .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Unity Multi Academy Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear circumstances for deviating from planned supervision
Wider context from the report “2. Had Owen been supervised as envisaged in his risk assessment, he would not have been able to consume the significant quantities of blue paper towel found in his mouth and throat. The class teachers’ evidence was that after her initial training, the process of advice on prioritising of supervision was retrospective in that she only received feedback on events that had already occurred. The current plan appears to permit the class teacher to deviate from the planned supervision and prioritising of supervision in circumstances that are not made clear.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations