In May 2013, 17-year old Rowan Stringer died as the result of a head injury she sustained while playing rugby with her high school team.

In the week prior to her final game, Rowan had been hit twice, and likely sustained a concussion each time. These concussions were not recognized, and she continued to play. When she was hit again in her last game, she suffered what is known as Second Impact Syndrome — catastrophic swelling of the brain caused by a second injury that occurs before a previous injury has healed. Rowan collapsed on the field, and died four days later in hospital.

A coroner's inquest was convened in 2015 to look into the circumstances of Rowan's death. The coroner's jury made 49 recommendations for how the federal government, as well as Ontario's government ministries, school boards and sports organizations should improve the manner in which concussions are managed in this province. Those recommendations can be found in Appendix A of this report.

The Rowan’s Law Advisory Committee was created through a private member’s bill in the Ontario legislature, with all-party support. Its mandate was to review the jury recommendations, as well as the broader concussion landscape, and to provide advice to government on how to implement the jury’s recommendations. In addition, our Committee was empowered to make other recommendations intended to prevent, mitigate and create awareness of head injuries in sport in Ontario.

Over the course of nine months, our Committee met eight times. We conducted a jurisdictional scan of concussion legislation and policy frameworks in Canada and in other countries. Committee members also monitored federal initiatives and maintained linkages with the Federal-Provincial/Territorial (F-P/T) work on concussions. Each of the coroner’s jury recommendations was reviewed, and the Committee developed a series of recommended Actions to ensure that each of the jury’s recommendations could be implemented.

Themes

The Committee established five themes, each of which was tied to a number of recommended Actions. These themes align with the Harmonized Approach adopted by the F—P/T Working Group on Concussions in Sport. They are: Surveillance; Prevention; Detection; Management; and Awareness.

In addition to these themes, our Committee makes a recommendation for legislation — Rowan’s Law — which crosses all five themes; and additional recommendations to ensure that all of our proposed Actions would be both broad in their reach and sustainable.

Recommended actions

The Rowan’s Law Advisory Committee recommends 21 different Actions, the full text of which can be found in Appendix D of this report.

Legislation — "Rowan’s Law"

  1. The Committee recommends the enactment of legislation, to be called "Rowan’s Law," which would govern all organized amateur sport – school-based (both public and private) and non-school-based — in Ontario. Key components of Rowan’s Law would include:
    • mandatory concussion education for athletes, parents/guardians, coaches, officials and educators
    • immediate removal from play for any athlete suspected of having sustained a concussion
    • medical diagnosis and a progressive return to learn and return to play based on Canadian and international concussion guidelines
    • codes of conduct for all amateur sport
    • collection of data about suspected and confirmed concussion; sharing that information with parents/guardians and with other teams/sports partners with consent; and analysis of data to make sure we are improving safety in amateur sport
    • declaration of an annual “Rowan’s Law Day”

Surveillance

  1. Public reporting to gauge the effectiveness of measures to improve safety in amateur sport
  2. Collection of data about removal from play for suspected concussions at the field of play
  3. Continued monitoring of existing concussion policy in our schools while legislation is enacted

Prevention

  1. Development and implementation of Codes of Conduct for all organized amateur sport, including Zero Tolerance policies for dangerous behaviours with high risk of causing concussions, and mandatory expulsions from play for violating the policy
  2. Standards and accountability for ensuring that playing surfaces are safe

Detection

  1. Requirement for at least one person, in addition to the coach(es), with specific training in concussion identification and management, at all games and practices
  2. Annual training for all coaches in concussion identification and management

Management

  1. Investment in an electronic solution for capturing, sharing and reporting information about incidents of suspected concussion at the field of play, and implementation of a manual, paper-based system in the interim
  2. Creation of special fee codes to ensure that physicians and nurse practitioners have the time to complete the necessary assessments and documentation for athletes sustaining a suspected or confirmed concussion, so that there is no charge to patients or their families for completion of these forms
  3. Creation of a "Coach’s Toolkit" with all necessary tools, protocols and forms to support best practices and ensure consistency across all amateur sport settings in Ontario

Awareness

  1. Inclusion of concussion prevention, detection and management in all teacher education training
  2. Re-branding of the existing Ontario.ca Concussion Portal under the name "Rowan’s Law," to serve as a repository for tools, resources and links related to concussion; and efforts to increase public awareness and use of this site
  3. Investment in a sustained public awareness campaign related to concussion
  4. Annual concussion education in our schools at all levels
  5. An annual concussion awareness education event for all Ontario schools, on or around Rowan’s Law Day
  6. Mandatory annual concussion education for all teachers and administrators at the start of each school year
  7. Enhanced education for health professionals around concussion detection, diagnosis and management, to ensure the use of a consistent, evidence-based approach and to increase capacity in our health care system to support the legislation and other Actions

Additional actions

  1. Recommendation to the Federal government to expand its work on a national harmonized approach to concussion to both school-based and non-school based amateur sports
  2. Working with First Nations leaders and stakeholders to encourage and support the dissemination and implementation of these or similar Actions in all First Nations communities
  3. Creation of a Rowan’s Law Concussion Partners Committee to ensure that the momentum which began with the creation of the Rowan’s Law Advisory Committee is sustained

Lastly, the Committee wants to stress that our aim is to encourage the safe participation in amateur sport — in fact, physical activity in general — by all Ontarians. We believe that Ontario, and Canada, can have the best concussion prevention and management system in the world, and that these Actions, if implemented together, will go a long way to getting us there. But we also believe that what is required, more than anything else, is culture change. Through increasing awareness, and changing the conversations that occur at our schools, on our fields of play, and in our homes, we can change the culture and make it easier for athletes to say when they are injured, and to get the help they need to return to play safely — athletes like Rowan Stringer.