A forensic report into the tragic death of Grade 8 Parktown Boys' High School pupil Enock Mpianzi revealed that an accurate roll call list, which was initially taken on departure at the school, was not available on site.
The initial roll call list was mistakenly left in the Iveco bus, which returned to Johannesburg after transporting the Grade 8 pupils to the orientation camp at Nyati Bush and River Break Lodge, near Brits in North West on Wednesday, 15 January.
The unavailability of the list subsequently led to confusion as to who exactly was at the camp when 13-year-old Mpianzi went missing following a water activity.
The damning report, which was compiled by Peter Harris of Harris Nupen Molebatsi Attorneys (HNM), was released during a parents' meeting and media briefing at the school on Wednesday night.
Other major findings include the water levels and the absence of life jackets during the water activity, where the boys experienced difficulty while on makeshift rafts.
Harris, who presented the report on Wednesday, said when the school needed to do a roll call check after the water activity at 17:30, another list had to be obtained from the school. However, that particular list contained all incoming Grade 8s and not just those who had attended the camp, which complicated matters.
It was at this point that it was realised that 11 pupils were missing and it was assumed they had not attended the camp.
The pupils were then taken into the field for their sleepout.
Harris revealed that only at 12:45 on Thursday was it realised that Mpianzi was missing. This after the parents had been called to check whether their boys attended the camp or not.
Mpianzi's father, Guy Intamba, indicated that he, along with family members, had accompanied Mpianzi and were present during the initial roll call at the school hall.
The report found that the school, together with its teachers, including the principal, Malcolm Williams, who accompanied the pupils, were negligent in not having an accurate and correct roll call list and they should be held accountable.
"The fact is that if they had the correct roll call list they would have realised 18 hours earlier the boy was missing and search attempts could have been activated," Harris said.
The report's findings also revealed that Williams, as the person who was in authority and bearing the responsibility as principal, neglected to enforce the necessary steps to accurately ensure who exactly was at the camp, especially after the water activity.
On arrival, the boys were divided into 15 groups. The law firm found that the names of the boys in each group should have been recorded, so that there could have been accountability of who was missing after the activity. However, that was not the case.
Williams and the camp coordinator, named as Mr Mentjies in the report, were "wrong and negligent" to assume the 11 pupils who were not present during a roll call following the water activity may not have attended the camp.
HNM Investigators conducted an inspection in loco at the site on 24 January 2020, where a camp manager, named as Mr Knoetze in the report, said the water level was a metre higher on the day than it had been on the day the boys went for an activity.
However, after further inspection, the law firm said it found that this was not true. They compared the level of the water to that from the day of the incident by using a picture which was taken by a teacher while the boys were in the water.
Harris said Mr Knoetze's view that the level of the water was a metre lower on the day was "misleading and false".
"In the circumstances, it is found that the evidence of Mr Knoetze in relation to the level of the river, when he said it was a metre lower on the day of the water exercise is incorrect and can be viewed as an attempt to mislead the HNM Investigation Team," the report reads.
The report also revealed that there were insufficient controls to ensure the safety and care of pupils at the river site, and that there were only a few facilitators.
"It is, therefore, found that the educators from the school, who observed the water exercise and who failed to ensure there were adequate safety and control measures to ensure the safety of the learners in their care, are guilty of negligent conduct."
Shortly after the discovery of Mpianzi's body, a probe into his death got under way and a preliminary report by the Gauteng Education Department (GED) found that the camp was not approved by the district.
As a result, Williams and several district officials were suspended.
Lesufi said the GED believed the officials had a case to answer for in processing the application by Parktown Boys' High School. He said it should be required that all safety aspects of an application be adhered to.
The report also found that no authorisation was granted for the school to go on the trip and that the permission granted to the school to go on the trip was incompetently handled by the district staff responsible for handling application forms.
"It is found that, as the principal, Mr Williams is the person ultimately responsible and he signed the authorisation form. He was negligent in not ensuring the proper authorisation was granted before the school undertook the Grade 8 orientation camp at Nyati.
"It is found further that the school governing body is jointly responsible in relation to the camp taking place without the requisite authorisation," the report further states.