Appendix A: Rowan Stringer coroner’s inquest jury recommendations
Recommendation 1
That the Government of Ontario adopt an Act (“Rowan’s Law”) governing all youth sport, both school-based and non-school based, which establishes the International Concussion consensus guidelines (Zurich) on Management of Concussion in Sports as the standard of practice for concussion management.
The Act should recognize the importance of four criteria in protecting children and youth:
- Providing education on sport-related concussions to athletes, coaches and parents:
- Removing a child or youth athlete from play if a concussion is suspected;
- Ensuring the child or youth does not return to play until he or she has received medical clearance; and
- Ensuring appropriate return to learn and return to play strategy is in place.
Recommendation 2
The Canadian Institute for Health Information (CIHI) [which includes the Ontario Trauma Registry (OTR) and the National Ambulatory Care Reporting System (NACRS)], the Public Health Agency of Canada’s Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP), the Ontario Ministry of Health and Long Term Care and the Ministry of Tourism, Culture and Sport should enhance the existing reporting system(s) to improve the accuracy of injury categorization and details so that the number of incidents and the effectiveness of injury prevention measures can be assessed in sports.
Recommendation 3
Ministry of Tourism, Culture and Sport should adopt and promote for all youth field sports the Zurich Guidelines on Management of Concussion in Sports as the standard of practice for concussion management. Opportunities to utilize public service announcements (PSAs) and media channels should be pursued.
Recommendation 4
Ministry of Tourism, Culture and Sport should acquire and make available information and resources to support parent, coach, player, referee and trainer education using resources from Parachute Canada, Ontario Physical and Health Education Association (Ophea), the Canadian Concussion collaborative and the U.S. Centre for Disease Control.
Recommendation 5
Ministry of Tourism, Culture and Sport should mandate that prior to the start of any higher risk (as defined by Ontario Physical and Health Education Association (Ophea)) youth sports activity, parents and athletes sign a participation agreement confirming that they have participated in a pre-season concussion awareness management session; they understand the signs and symptoms of concussion.
Recommendation 6
Ministry of Tourism, Culture and Sport should foster a culture of fair play by mandating the use of codes of conduct for all players, coaches and parents.
Recommendation 7
Ministry of Tourism, Culture and Sport should develop and mandate the use of pre and post-game/practice mechanisms to check with team members to identify any injuries or concerns about a player’s well-being. In the event of suspected injuries, players/parents should be encouraged to seek medical attention.
Recommendation 8
Ministry of Tourism, Culture and Sport should promote and encourage communication between community and high school sports coaches to support safe play and the well-being of student athletes. This should include consistent messaging and practice regarding Return To Play. This could be done by communicating through parents, a passport, electronic messaging or other method that respects the privacy of the individual, but ensures the key information is shared and actioned.
Recommendation 9
Ministry of Tourism, Culture and Sport should require the use of a standardized Coach’s Binder, containing sample forms and material such as: medical and emergency contact information forms, tracking tools for specific player injuries, a concussion recognition tool, contact information for coaches of other concurrent sports, forms to help track attendance at practices and mandatory injury prevention sessions, permission forms and other documentation of best practices in the particular sport.
Recommendation 10
EDU should provide funding to school districts to support the full implementation of PPM 158.
This should include funding to cover the costs associated with proposed changes to the Ontario Safety Guidelines (OSG) effective September 2016 re: certifications and requirements for coaching and first aid.
Recommendation 11
EDU should develop an evaluation program to ensure compliance with PPM 158 on concussions to monitor and measure effectiveness in all school-based sports activities.
The results of these evaluations should be publicly reported, and incentives should be considered to encourage high-quality implementation.
Recommendation 12
EDU should develop a PPM similar to the current PPM 158 on concussions for private schools which includes the same concussion education activities and management guidelines as PPM 158.
Recommendation 13
EDU should facilitate the implementation of PPM 158 to support the unique needs of families whose first language is other than English or French by making resources available to school districts, such as a concussion identification tool, in multiple languages.
Recommendation 14
EDU should revise the Ontario curriculum to ensure that education regarding concussion awareness and management is a mandatory part of elementary and secondary school curriculum, integrated into science, health and physical education and other areas of study as appropriate for the age of the student.
Curriculum models should be developed by reviewing existing models and best practices of school boards across the province.
Recommendation 15
EDU and Ophea should develop a training module for school district employees on concussion awareness, prevention, Return to Learn and Return to Play strategies.
Recommendation 16
EDU, Ophea and OSBIE should develop a method of tracking student concussion injuries: to follow and ensure those students with concussions are treated appropriately, to ensure the Return to Learn and Return to Play process is respected and to provide clear data to assess the effectiveness of concussion prevention and management.
The anonymized data should be available for public reporting and assessment of the effectiveness of concussion prevention efforts.
Recommendation 17
When implementing PPM 158, all school boards in Ontario should adopt the International Concussion Consensus Guidelines (Zurich) on Management of Concussion in Sport as the standard of practice for concussion management.
Recommendation 18
When implementing PPM 158, all school boards in Ontario should ensure all students, parents/guardians, teachers, school administrators, coaches, trainers and referees are educated about the symptoms and signs of concussion.
Recommendation 19
When implementing PPM 158, all school boards in Ontario should acquire and make available information and resources to support education by using resources from Parachute Canada, Ophea, the Canadian Concussion Collaborative and the U.S. Centre for Disease Control.
Recommendation 20
When implementing PPM 158, all school boards in Ontario should ensure that prior to the start of any higher risk school team sports activity, parents and athletes sign an agreement confirming they have participated in a pre-season concussion awareness and management session.
In addition to the participation, the Agreement should: identify the sport, confirm that the sport is considered higher risk under the OSG, provide information about the OSG, provide details regarding the play and practice schedule and a reminder of their responsibility to report any injuries including concussion or suspected concussion.
Recommendation 21
When implementing PPM 158, all school boards in Ontario should foster a culture of fair play by mandating the use of codes of conduct for all players, coaches and parents.
Recommendation 22
When implementing PPM 158, all school boards in Ontario should develop and mandate the use of pre and post-game/practice mechanisms to check with team members to identify any injuries or concerns about a player’s well-being.
In the event of suspected injuries, players/parents should be encouraged to seek medical attention and appropriate injury reporting undertaken.
Recommendation 23
When implementing PPM 158, all school boards in Ontario should promote and encourage communication between community and high school sports coaches to support safe play and the well-being of student athletes. This should include consistent messaging and practice regarding Return to Play. This could be done by communicating through the parents, a passport, electronic messaging or other method that respects the privacy of the individual, but ensures the key information is shared and actioned.
Recommendation 24
When implementing PPM 158, all school boards in Ontario should require the use of a standardized Coach’s Binder, containing sample forms and material such as: medical and emergency contact information forms, tracking tools for specific player injuries, concussion recognition tool, a contact information form for coaches of other concurrent sports, forms to help track attendance at practices and mandatory injury prevention sessions, permission forms and other documentation of best practices in the particular sport.
Recommendation 25
When implementing PPM 158, all school boards in Ontario should adopt an annual awareness and learning opportunity for students, such as “Brain Day” (by Parachute Canada), or a module designed by Ophea, to ensure all students are annually provided consistent and accurate information.
Recommendation 26
When implementing PPM 158, all school boards in Ontario should implement a mandatory learning module on concussion as part of the Grade 9 Health and Physical Education curriculum.
Recommendation 27
When implementing PPM 158, all school boards in Ontario should ensure that as OSG are renewed, all teachers involved with Sports programs and Physical Education are required to read and confirm their review of the guidelines with the Principal and/or Athletic Director of their school.
The confirmation of its review should be mandatory and recorded.
Recommendation 28
When implementing PPM 158, all school boards in Ontario should ensure that all First Aid kits in schools contain an appropriate Concussion Recognition Tool.
Recommendation 29
When implementing PPM 158, all school boards in Ontario should ensure that information about concussion policy/procedure and management is part of NTIP.
Recommendation 30
When implementing PPM 158, all school boards in Ontario should consider adopting a full school year rugby season to allow for the development of the necessary skills with the view that this could help address the noted issues around scheduling all the required games and practices into a limited time.
Recommendation 31
Rugby Canada, Rugby Ontario, the Eastern Ontario Rugby Union, OSBIE and Ophea should set a standard for rugby field quality to ensure that the surface is safe for youth athlete play.
- This recommendation should be applied as appropriate to other higher risk sports (e.g., football)
Recommendation 32
To enhance the safe play of rugby in club sports and in schools, Rugby Canada, Rugby Ontario, the Eastern Ontario Rugby Union, the Ontario Boards of Education, OSBIE, and Ophea should implement mandatory pre-season safety sessions for sport teams for athletes and their parents.
These sessions for higher risk sports should cover the symptoms and signs of concussion, reporting of the suspicion of concussion, exclusion of those suspected of concussion, and proper concussion management, including Return To Learn and Return To Play.
A personal story/video, such as that of Rowan Stringer, should be an integral part of the safety training. Attendance is to be taken and recorded.
Athletes should not be permitted to participate in play until this education has occurred.
- This recommendation should be applied as appropriate to other higher risk sports (e.g., football)
Recommendation 33
To enhance the safe play of rugby in club sports and in schools, Rugby Canada, Rugby Ontario, the Eastern Ontario Rugby Union, OSBIE, and Ophea should adopt a policy of zero tolerance of head hits and high tackles at any level of play in rugby, and should be penalized with progressive penalties, including expulsion for repeat offenders.
- This recommendation should be applied as appropriate to other higher risk sports (e.g., football)
Recommendation 34
To enhance the safe play of rugby in club sports and in schools, Rugby Canada, Rugby Ontario, the Eastern Ontario Rugby Union, OSBIE, and Ophea should give consideration to the use of snug fitting collarless rugby jerseys, to decrease the incidence of dangerous tackles (e.g., "swing" tackles) during play or practice.
Recommendation 35
To enhance the safe play of rugby in club sports and in schools, Rugby Canada, Rugby Ontario, the Eastern Ontario Rugby Union, OSBIE, and Ophea should give consideration to the presence of an assistant referee during all youth rugby games.
Recommendation 36
To enhance the safe play of rugby in club sports and in schools, Rugby Canada, Rugby Ontario, the Eastern Ontario Rugby Union, OSBIE, and Ophea should ensure that a minimum number of coaches (two at the least) be present for each youth rugby team playing on the field.
Recommendation 37
To enhance the safe play of rugby in club sports and in schools, Rugby Canada, Rugby Ontario, the Eastern Ontario Rugby Union, OSBIE, and Ophea should determine an optimum safe time interval between rugby games or practices involving contact to decrease the risk of concussion or other preventable injury, particularly for those youth athletes who compete in more than one league.
Recommendation 38
To enhance the safe play of rugby in club sports and in schools, Rugby Canada, Rugby Ontario, the Eastern Ontario Rugby Union, OSBIE, and Ophea should give further consideration to requiring the presence of an athletic trainer/therapist in school higher risk sports, both during practice and during games.
Recommendation 39
To enhance the safe play of rugby in schools, OSBIE and Ophea should ensure that the head coach of a high school rugby team attain a minimum of level 1 coach qualification, as per Work Rugby standards.
All rugby coaches should meet, at a minimum, the Ophea requirements for rugby coaching in the OSG.
Recommendation 40
EDU and the Public Health Agency of Canada should gather, monitor and publish the response to the concussion questions placed in the Health Behaviour in School Aged Children Survey, administered by Queen’s University and the Public Health Agency of Canada, with a view to assessing the impact of concussion prevention initiatives over the long term.
Recommendation 41
Ministry of Health and Long-Term Care, the OMA, Ophea, Ontario School Boards should ensure that there will be no fee charged for documentation by a physician to assess a student for a suspected concussion when providing guidance for Return to Learn and Return to Play.
Recommendation 42
EDU, OCT and TCU should ensure that all students enrolled in BEd programs have first aid certification, including concussion awareness, prevention and management.
Recommendation 43
EDU, OCT and TCU should ensure that all students enrolled in BEd programs receive a mandatory athletic coaching course, to ensure standardized training of all new teachers whether or not they plan to coach athletics, and to encourage teacher participation as athletic coaches.
Recommendation 44
The Royal College of Physicians and Surgeons of Canada, College of Family Physicians of Canada, the Canadian Medical Association and the Provincial Ministries of Colleges and Universities include specific components of sports related injuries including the diagnosis and management of concussions to the course content at all medical schools to ensure a more uniform standard of treatment.
Recommendation 45
The Royal College of Physicians and Surgeons of Canada, College of Family Physicians of Canada, the Canadian Medical Association and the Provincial Ministries of Colleges and Universities require that accredited programs for family physicians are updated to emphasize concussion awareness, diagnosis and management as noted in the Zurich Guidelines.
Recommendation 46
The Canadian Red Cross Society, St. John Ambulance, and the Lifesaving Society should ensure concussion awareness and management is included in all First Aid training. This should include the signs and symptoms of concussion, potential catastrophic results of improper concussion management and the use of the Zurich Guidelines.
Recommendation 47
Parachute Canada and Ophea should collaborate to develop multimedia learning resources on concussion awareness, based on the story of Rowan Stringer, ideally involving individuals closely associated with Rowan.
These resources should be widely available in a variety of media in order to motivate high school athletes and their teammates to report suspected concussions.
Recommendation 48
Parachute Canada and Ophea should collaborate to develop an online concussion information module that could be used as a pre-season awareness session, to make it easier to share the information at the beginning of a higher risk sports season.
Recommendation 49
The Federal, Provincial and Territorial Ministers Responsible for Sport should play a leadership role in raising awareness regarding the education of players, parents and officials and for the management of concussions in sports that occur in non-school environments. Guidelines similar to those in Policy/Program Memorandum No. 158 (PPM 158) of the Ontario Ministry of Education covering sports in schools could be used as a model.