Gunma Issues Guidance After Death of Disabled 17-Year-Old on Outing, Cites “delay in transporting to hospital”

From The Mainichi Shimbun via Yahoo! Japan

January 25 2026

GUNMA – It has been learned that Gunma Prefecture issued guidance to a social welfare corporation operating a disability support facility following an investigation into an accident in which a male high school student (17 at the time), who attended a disability support facility in Ōra Town, Gunma Prefecture, fell ill and died during a sea swimming outing. The prefecture cited a “delay in transporting him to a hospital” as a contributing factor and pointed out that countermeasures against aspiration of seawater had not been discussed, stating that “risk management was not in place.”

According to the prefecture’s investigation results, the accident occurred during an “overnight educational trip” held in August 2024, when the group went swimming at the sea in Niigata Prefecture. On the return trip in the vehicle, the student’s breathing weakened and he vomited, after which his breathing could no longer be confirmed. The facility called emergency services and performed cardiopulmonary resuscitation. The student was hospitalized and admitted to an intensive care unit but later died. The cause of death was diagnosed as a combination of drowning and pulmonary edema due to aspiration of seawater, along with preexisting medical conditions.

According to those involved, the facility was an after-school day service (hōdei) in Ōra Town. As the prefecture is responsible for designating disability child day-service providers such as hōdei, and in light of a notice from the Children and Families Agency requiring reporting of fatal accidents and measures to prevent recurrence, the prefecture began an investigation together with the town.

After receiving a report from the facility, the prefecture conducted an on-site investigation in December 2024. The facility explained the student’s condition as follows: “A staff member noticed his lips were blue and brought him up onto the beach. Another staff member said he ‘seemed unwell,’ and while washing his body at a faucet, his legs were shaking.” Regarding the return trip by car, the facility reported, “We thought we could let him go home as is,” and said that taking him to a hospital was deemed unnecessary, as they believed it to be a mild case of heatstroke.

Inadequate Measures Against Aspiration; Lack of Coordination With Medical Institutions

In February 2025, after receiving an investigation report from an external committee, the prefecture issued improvement guidance in May. It pointed out that “approximately two hours elapsed from when the student’s poor condition was recognized until his condition rapidly worsened and he lost consciousness. The failure to transport him at an early stage may have contributed to the severity of the outcome.” The prefecture also cited as contributing factors that prior meetings focused mainly on heatstroke and jellyfish countermeasures, that no discussion had taken place on preventing aspiration of seawater, and that risks related to the student’s preexisting conditions had not been properly assessed.

Regarding the operator’s response, the decision to return from Niigata Prefecture to Gunma Prefecture was deemed not to constitute a “serious defect,” as “until just before he lost consciousness, he was unstable but able to walk on his own and respond when called.” At the same time, the prefecture noted that “prioritizing safety, an early decision to transport him to a hospital should have been made.”

The prefecture further identified the lack of coordination with medical institutions as “one of the reasons that a decision to seek medical care was not made.” Ministerial ordinances under the Child Welfare Act stipulate that when a child with disabilities experiences a sudden change in condition, necessary measures must be taken, such as promptly contacting a medical institution, and the prefecture called for improvements.

The Mainichi Shimbun obtained materials and minutes from a briefing session held by the facility for parents. According to these, it was the facility director who instructed staff to return to the facility in Gunma Prefecture—a drive of about three hours—from the beach in Niigata Prefecture. While parents were contacted by phone, the student’s regular physician was not contacted, and no staff member with professional qualifications such as a nursing license accompanied the group.

Although the facility had checked nearby medical institutions in advance in case of participants becoming unwell, it had not directly confirmed whether those institutions would accept patients. Another person involved with an after-school day service commented, “When disabilities are severe, medical institutions may sometimes refuse treatment. Coordination with medical institutions is always necessary.”

The bereaved family said they feel that “if he had been taken to a hospital, he might have survived.”

According to the prefecture, the corporation has stated that, following the guidance, it will revise its safety manuals and conduct staff training. The Mainichi Shimbun sent the corporation two written inquiries seeking clarification of the facts at the corporation’s request, but no response was received even after the deadline had passed by four months.

After-School Day Services

Facilities that children with disabilities who attend elementary, junior high, or high school can use after school, on holidays, and during long school breaks. Based on individualized support plans tailored to each child, the aim is to foster daily living skills and social development through play, learning, and interaction with the local community. The system was established following a revision of the Child Welfare Act in 2012. Users generally bear 10% of the cost, with the remainder covered by public funds from the national and local governments. According to the Ministry of Health, Labour and Welfare, as of October 1, 2024, there were 22,643 such facilities nationwide, with 633,631 actual users in September of the same year.