The four- day inquest hearing into Leo's death concluded today at Essex Council chambers.
A jury returned a narrative verdict that Leo Latifi died as a result of an accident.
They said the accident was significantly contributed to by a lack of appropriate assessment to a clear and obvious risk in relation to a locker-unit not being re-secured to a solid wall as per manufacturer's instructions. This remained the case for an extensive period of time.... some six years.
"We the jury agree that inadequate precautions and training measures were taken to address this failure and therefore prevent Leo Latifi's death."
During the inquest, Senior Coroner Caroline Beasley-Murray and jury heard evidence confirming that the locker unit was not secured to the wall at the time of the incident, and likely had not been attached to the wall for several years. In addition, a number of locker doors were missing from the locker unit.
The court heard from various witnesses, ranging from building contractors, members of staff from the school, and representatives from the Health and Safety Executive (HSE), locker manufacturer and swim school company.
The evidence at the inquest indicated that the most likely position was that the lockers were secured to the wall at the time of installation in 2006. However, the flooring in the changing rooms was replaced in 2013/14 by an independent contractor, in the course of which the lockers were removed and then subsequently not fixed back to the wall.
A specialist mechanical engineer from the HSE described the unsecured locker unit as 'inherently unsafe.' He highlighted that the unit was tall, narrow and heavy, such that if it were to fall over, the foreseeable outcome would be serious injury or death. He described the fixings provided by the manufacturer as an integral part of the locker unit, which were fundamental to the locker's installation.
The court also heard how experiments carried out following the incident demonstrated that when three screws were fitted through the fixings and the locker unit was secured to a solid structure, it was able to withstand at least five times the tipping force to that which applied to the unsecured locker.
Members of staff from the school provided evidence confirming that they did not even know the locker unit had fixings, and that they had not checked whether or not the locker was secured to the wall.
Evidence was also heard confirming that the school did not carry out or arrange any inspections of the locker unit fixings or any checks to ensure the unit was in a safe operational state.
Further, there was no risk assessment which identified the risk presented by the locker unit, nor any quality control system in place for the substance of risk assessments. As a result, the matter of whether the locker unit was secured to the wall and therefore stable was not considered or explored.
A pen portrait prepared by Leo's family was read out at the conclusion of the evidence, in which Leo was described as a boy who 'loved life and was always looking for his next greatest adventure.' A tribute from his teacher was included, describing him as an 'avid scientist' who 'lit up our classroom with his sparkling eyes and cheeky grin.'
Leo's parents, Eddie and Natalie Latifi issued a statement following the inquest. They said:
"Losing Leo has caused us the worst pain imaginable. We are now clear this tragedy should never have happened. We put our trust in the school who provided the premises for the swimming lessons, and we expected those premises to be safe.
"The significant risk posed by a large locker unit being unsecured to the wall should have been clear to those in positions of responsibility at the school. However, it seems that over many years, there was no adequate system of inspection or risk assessment at the school, and as a result, the obvious risk that this unit posed was never identified.
"All we can hope is that Leo's death means that similar incidents will not be allowed to happen, so that that no other family will have to experience our suffering, which will remain for the rest of our lives."
Leigh Day solicitor Sarah Saldanha represents the Latifi family. She said:
"Leo's death was a horrific and tragic incident which should have been avoided. Through the course of the Inquest, we have become aware of clear failings on a prolonged basis relating to inspections, maintenance, and risk assessments, all of which are integral to ensuring the safety of children on school premises.
"Despite the foreseeable danger of the unsecured locker unit toppling over, there was a failure to even identify this as a risk, let alone take measures to prevent such a risk materialising. These omissions are therefore of a serious nature and the Inquest has highlighted the importance of proper systems in relation to such installations.
"We are pleased that the Senior Coroner agreed that the procedural obligation under Article 2 of the European Convention on Human Rights (the right to life) is engaged, thereby highlighting the duties incumbent on state authorities. These core duties are encompassed within Article 2 to protect life and it is fitting that the threshold for engagement of this Article has been met."
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