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May 14th, 2013 
Peter Nolan
Updated
Keeping small children out of massage treatment rooms could have prevented the death of an infant who was crushed, said a coroner.
Sophie Ann Schulz, 18 months, died after she was pinned under an electric massage table as it was being lowered at the Fravira Clinic at Saint Morris in eastern Adelaide.
Her mother Justine Schulz was receiving treatment, in June 2009.
Deputy Coroner Anthony Schapel released his findings on the child’s death, saying it had been foreseeable.
Mr Schapel said no one had the sole responsibility for supervising children in the treatment area.
“During the course of this massage Mrs Schulz’s children, Sophie and her son Regan who was four years of age at the time, were present in the room and playing. No person who had the sole task of directly supervising the two children was in the room,” he said.
“When the table was lowered by the therapist, Sophie’s head was trapped in the moving mechanism beneath the table. At some point she had moved to a position under the table and had done so unnoticed.
“In the course of her mother’s evidence at the inquest, Sophie was described as a busy, very curious and very playful little girl who enjoyed interacting with her older brother. She enjoyed exploring the world and playing. She was already very mobile. She could climb up onto things such as a chair or a table. She had been walking since just before her first birthday. She could run without tripping. She could move quite quickly on her feet.”
No warnings
Mr Schapel said management of the clinic had not instructed staff against allowing children into the treatment rooms, but staff said “child-minding” was not part of their duties.
“Mrs Schulz told the inquest that no warning had ever been given to her by any staff members at the clinic as to the risk that might have been presented to children. She did not perceive any danger that might have been presented to children within the treatment room,” the Deputy Coroner said.
“Nothing was ever said to her specifically about dangers associated with the tables. She was not deterred from bringing her children to appointments.
“If she had been told anything about the dangers presented by the tables she would not have taken her children to appointments.”
Mr Schapel said the environment was unsafe for an infant.
“A child of 18 months of age would be completely oblivious to the dangers posed by the machinery. One only has to contemplate an 18-month-old child alone in a room with this machinery in operation to appreciate how dangerous a situation that would be. One does not have to have the benefit of 20/20 hindsight to state such an obvious proposition,” he said.
Mr Schapel said children should be banned from treatment rooms where such massage equipment was used.
He said it was not surprising a child might be attracted to moving machinery.
“To my mind it was foreseeable to staff who worked in the premises, and in particular to those who operated the machinery and saw it working on a daily basis, that a child might be attracted to and place a body part in the moving machinery,” he said.
“Given the accepted presence of a small child in the room, the only sure way that this could have been prevented would have been for constant vigilance and sight of the child to be maintained for the whole of the duration of any lowering operation. Clearly that did not take place in this case.”
To my mind it was foreseeable to staff who worked in the premises, and in particular to those who operated the machinery and saw it working on a daily basis, that a child might be attracted to and place a body part in the moving machinery
Prevention
Mr Schapel concluded there were a number of ways the tragedy could have been avoided.
“Sophie Schulz’s death would have been prevented if small children were not permitted within treatment rooms, and probably would have been prevented if management of Fravira Clinic had insisted that small children who were present in a treatment room be supervised by an adult who was a person other than those participating in the treatment,” he said.
“[It] may have been prevented if staff had been regularly reminded verbally and in writing to ensure small children did not venture under massage tables at any time, especially when the table was being lowered.
“The court is of the view that the experience of this case would strongly suggest the only certain method by which such an incident could be prevented in the future would be not to permit children to be present in a room where such equipment resides or to have an age-appropriate child constrained within the room by means of a playpen.”
Mr Schapel recommended SafeWork SA issue a notice that in no circumstances should a child be present in a room in which a moving massage table existed, except in the case of an age-appropriate child who could be put in a playpen.
He recommended Standards Australia “consider researching and implementing a standard whereby massage tables with exposed lowering mechanisms should be required to have guards attached in order to prevent accidental access by a person to the working mechanism”.
Legal conflict
The Deputy Coroner mentioned the difficulty posed by his inquest having run at the same time as a criminal prosecution of the Fravira Clinic and its proprietor Elvira Brunt.
That prosecution in the Industrial Court was dismissed.
“It is difficult for a coronial inquest to be conducted while a prosecution is either being considered or once instituted has not been concluded,” he said.
“There appears to be no sensible reason why, as in another Australian jurisdiction, there ought not be a legislative regime whereby a witness in coronial proceedings can be compelled to truthfully answer questions, notwithstanding that the answers might incriminate him or her in respect of an offence, but on the understanding that they will be issued a certificate or other type of assurance that the evidence that they give will not be used in any subsequent court proceedings,” he said.
“This very valuable investigative tool is not available to the coronial jurisdiction in South Australia and its absence in many instances may either act to the detriment of the integrity of coronial proceedings or renders them futile.
“I draw this issue to the attention of the Attorney-General for his consideration.”
Topics:
courts-and-trials,
law-crime-and-justice,
death,
st-morris-5068,
adelaide-5000,
sa,
australia
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Source Article from http://www.abc.net.au/news/2013-05-14/infant-massage-table-death-finding/4688060
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