A coroner has found that a systematic failure by the Education Department contributed to the death of a Latrobe High School student in 2009.
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Coroner Rod Chandler handed down his findings into the death of Rene Levi in front of a packed courtroom in Devonport this morning.
Rene was 15 when he drowned in the Mersey River at Bells Parade during a school excursion on November 16, 2009.
Mr Chandler also found that the senior teacher, Tim Jolly, contributed to Rene's death.
``Critically, he was the sole person who took responsibility for the supervision of the swimmers.
``Mr Jolly failed to discharge this responsibility by properly supervising Rene and this failure was, in my view, a factor contributory to the death.''
Mr Chandler said three other teachers and a student teacher could not be blamed for contributing to Rene's death, nor could the school principal Phil McKenzie.
However, he said, the department ``failed to ensure that the principal and staff at Latrobe High were sufficiently aware of and fully understood the guidelines''.
``The failure on the department's part to ensure that Mr McKenzie and his staff were aware of and fully understood the guidelines was a factor which contributed to Rene's death.''