Safety failings at a school contributed to the death of a blind and wheelchair-bound pupil after he fell down a flight of stairs.
15-year-old Muhammed Ghafoor suffered severe head and spine injuries as a result of the accident in a playground at Mayfield School in Lozells, Birmingham.
He was taken to Birmingham Childrens Hospital but died four days later.
An inquest jury concluded that the teenager had died as a result of an accident - but said his death had been contributed to by neglect.
In a narrative verdict they said:
"There was no risk assessment for the playground for wheelchair users. There was insufficient levels of staff in the playground and no brakes had been applied on the wheelchair".
– Jury verdict
During a two-day inquest the jury heard that Muhammed had severe learning difficulties and was unable to push himself in his wheelchair.
Muhammed had been wheeled on to an upper level part of the playground during the lunch break and was near to the steps where there was no barrier.
There were four members of staff near to the teenager. But they had walked away from him when one heard a “scream”, the inquest heard.
A safety expert concluded that Muhammed would not have been able to reach the wheelchair brakes, which must have been off.
He said the wheelchair had moved because of the movements of Muhammed himself and because it had been a blustery and windy day.
Coroner Louise Hunt said:
"He was wheelchair dependant and the need for supervision was obvious. Four members of staff left the 15-year-old unsupervised placed at the top of stairs".
– Coroner Louise Hunt
Following the jury’s conclusion, the coroner said steps had now been put in place to change the system at the school.
Afterwards Abdul Ghafoor paid tribute to his son who he said suffered from a rare condition called Peter’s Syndrome.
"He liked to go on holidays and have adventures. He loved music. He was bubbly and warm and loved to hug and cuddle people. There were failures and it is something that could have been prevented".
– Father, Abdul Ghafoor