Published Tuesday, 03 September 2013
Benjamin Robinson, aged 14, collapsed on the field while playing rugby for Carrickfergus Grammar School in January 2011.
He had been momentarily knocked out at the start of the second half and he was involved in a number of heavy tackles.
Coroner Suzanne Anderson described how Ben was a talented and enthusiastic rugby player and she expressed her deepest sympathy for the family.
She told the inquest in Belfast she believed the teenager had sustained concussion during a heavy collision with another player at the start of the second half but, despite his injury, had played on for a further 25 minutes.
"I am satisfied that he sustained concussion in the first four minutes of the second half. Unfortunately neither the team coach or the referee were made aware of his neurological complaints and he continued to play," Ms Anderson said.
"I accept the consensus opinion that the features of this death are typical of second impact syndrome which occurs when two concussive-type injuries are sustained in a short space of time. It is exceptionally rare but can affect young people between 14 and 18 whilst engaged in sporting activity.
This is the first recorded death of its kind in Northern Ireland and most probably the first in the UK.
Coroner Suzanne Anderson
The coroner added: "Medical science is not able to ascertain why an individual can succumb to this exceedingly rare syndrome."
Sudden impact syndrome causes a swelling of the brain and some research points to children being more susceptible to it than adults.
The coroner said she would present her findings to the head of Irish rugby and Stormont's Education Minister to highlight the dangers of second impact syndrome and raise awareness about concussion management.
Speaking after the inquest, Ben's family said they want to see proper legislation introduced for sport in schools, to ensure awareness of concussion management.
"We welcome the coroner's findings and the recognition that there was a concussion and pointing out of the failings in the system," Ben's father Peter said.
He said they would be arranging to meet the Education Minister John O'Dowd to put the case for 'Ben's Law' forward.
Ben's mother Karen Walton was visibly distraught outside court and described how he had slept in his rugby kit the night before the game.
She commented: "He did not want to let anybody down in the match and the adults there let Benjamin down."
In a statement the school said Ben's tragic death "caused such trauma and grief within our school community".
"We hope today's findings offer some closure to this heartrending tragedy."
The Irish Rugby Football Union (IRFU) and Ulster Rugby have said player safety is a priority.
"The IRFU and Ulster Rugby would like to once again express our deepest condolences to the family of Benjamin Robinson," a spokesman said.
"Injuries of this nature are highly unusual in rugby. The IRFU and Ulster Rugby observe all international best practices, as set out by the International Rugby Board.
"We have in place, and continue to develop, education and training campaigns to ensure player welfare is prioritised at all times."
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