A 12-year-old boy who died after he fell while trying to slide down a banister at the top of a school stairwell had been caught attempting a similar manoeuvre just hours earlier, an inquest has heard.
Year 7 pupil Michael Sousa sustained severe head injuries when he fell at Jane Austen College in Norwich on January 23 this year.
Norfolk's senior coroner Jacqueline Lake concluded that his death, eight days later in hospital, was misadventure.
Detective Sergeant Peter Wilson of Norfolk Police, told the inquest in Norwich that it appeared Michael fell from the top floor of the stairwell - the third floor - to the bottom.
DS Wilson said Michael was wearing a backpack at the time which was 'full' and 'quite heavy'.
He said pupils described how Michael had been sliding down the banisters when he fell.
Michael fell at around 3.30pm, just after classes were let out.
At around lunchtime on the same day, modern languages teacher Jamie Turner said he saw Michael sliding down banisters from the first floor.
Giving evidence at the inquest he said he told Michael to 'walk back down the stairs appropriately'.
He added: 'He reluctantly did do that.'
Three children who witnessed the incident on the third floor were interviewed by specialist police officers.
One said Michael leaned over the banisters with his stomach to slide down then the backpack rode up his back as if to pull him over. A second pupil gave an account that was broadly similar.
A third pupil, child C, gave an account that an unidentified pupil accidentally knocked Michael over as he 'rushed past' on the stairs, but this was investigated, more than 15 pupils were spoken to and no similar accounts were given.
Overall, the general impression was that Michael had been leaning over the banister to slide down to the next level and toppled. His heavy rucksack could have unbalanced him.
DS Wilson added: 'I believe the bag has caused that unbalance that has caused Michael to fall over the banisters.'
Michael's fall was the day after his 12th birthday, and he died at Addenbrooke's Hospital in Cambridge of a severe traumatic brain injury at on January 31 2017.
The inquest heard an Ofsted inspection held in October 2016 - just three months before Michael fell, found pupil safety to be 'very effective' with the school rated as good with outstanding elements.
Rebecca Handley Kirk, acting college principal at the time, said pupils were taught how to behave on stairs during their inductions and reminded during periods and assemblies.
She also told the inquest how staff 'sweepers' would walk up the stairs during breaks and lunchtimes to ensure that children were moving down the stairs appropriately.
Paul Carter from the Health and Safety Executive (HSE) said they found the stairwell and rails were compliant and provided a 'good standard of protection for those that were using the stairwell in a reasonable manner'.
In reaching her conclusion, Mrs Lake said: 'I'm satisfied, from the evidence I've heard, that Michael went on to the stair banister with the intention of sliding down it and clearly that's not its purpose.
'Although a number of children gave slightly differing accounts, they do support the contention that Michael went onto the banister, lost his balance then fell down.'
She added: 'This was an intentional act which had unintentional consequences and in those circumstances my conclusion is misadventure.'
Mrs Lake said Michael's death was 'clearly a great tragedy for everyone concerned'.
She offered her condolences to Michael's family, including his mother Sandra Rodriguez, who attended the inquest hearing.
Following the inquest, James Goffin, a spokesman for the Inspiration Trust, which owns Jane Austen College, said: 'Our thoughts throughout have remained with Michael's family and friends, and we again offer them our sincere condolences.
'The coroner, the Health & Safety Executive, and the police investigations all came to the same conclusion that this was a tragic accident which occurred despite the school having very high standards of safety and behaviour.
'Michael was a lively and friendly boy, and these events have been desperately sad for us all.'
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