News & Events

DEATH INQUEST: Coroner finds teacher’s suicide preventable, recommends improvements to school complaints procedure

Ms Lam Lai-tong, teacher at TWGHs Leo Tung-Hai Lee Primary School, fell to her death from the school building in March 2019. Following a nine-day inquest, the Coroner ruled that Ms Lam was driven to suicide by the actions of then school principal Ms Law Yuen-yee and that her death could have been avoided. The Coroner adopted the 19 recommendations suggested in the Incident Investigation Report by the Independent Investigation Committee, including suggested measures to protect the identity of school complainants. Jeffrey Tam represented the Hong Kong Professional Teachers’ Union, a properly interested person in the death inquest. 


The learned Coroner Ms Monica Chow Wai-choo delivered her verdict on 29 January 2021. She found that Ms Lam was driven to suicide by the actions of the then school principal who pressured her to resign. The tragedy was triggered by Ms Lam’s failure to issue formal notice to students’ parents about an upcoming learning trip to Macau; her subsequent meeting with the principal on 5 March 2019 pushed her over the edge and led to her mental breakdown.

The inquest heard that after Ms Lam failed to issue formal notice to students’ parents about the trip, the school principal did not blame the two other teachers involved in organising the trip. Instead, she reprimanded Ms. Lam, telling her that she might lose her job and her provident fund if she made another blunder again.

On 5 March 2019, after Ms Lam compiled a report on her mistake, she was called to the principal’s office for another round of scolding. A teacher witness recalled that Ms Lam cried hysterically after the meeting, before calmly saying that she and the principal would “perish together”.

On the same day, Ms Lam left school early to file a complaint to Tung Wah Group of Hospitals (TWGH), the school’s sponsoring body. Her complaint was handled by an education services officer who just took over the role shortly before. The officer believed that the incident was “not complicated”, and he was not aware of any problems with the school’s governance nor two anonymous complaint letters in 2015 filed against the then school principal. With a view to soliciting background information, the officer informed the then school principal of Ms Lam’s complaint without maintaining her anonymity.

Ms Lam jumped to her death at the school at about 7am the next day. About five months after her death, the then school principal was terminated from her position. 

Hong Kong Professional Teachers’ Union, as the largest trade union of teachers in the territory, had been listed as a properly interested person in this matter and was allowed to make representation in this inquest.

Coroner’s finding – Ms. Lam’s death was preventable

In the verdict, the Coroner ruled that Ms Lam’s life could have been saved had her complaint remained confidential or had either of the two other teachers involved in arranging the trip shouldered responsibility for the mistake. The failure within TWGH’s complaint mechanism and the lack of support and care from Ms Lam’s colleagues were factors which contributed to the tragedy.

Coroner’s recommendations – Staff handover and complaints procedure

The Coroner adopted the 19 recommendations suggested in the Incident Investigation Report by the Independent Investigation Committee on improving TWGH’s school governance, including:

• Protection of complainants’ identity: The Coroner recommends that in future, following meetings with a complainant, the relevant TWGH department should:

clearly inform the complainant that the matter would be handled in confidence;
– refrain from disclosing the complainant’s identity unless it has obtained the complainant’s consent to do so;
– annually submit a stakeholders’ report to the school’s management committee for discussion.

• TWGH staff handover arrangements: The education services officer was not aware of anonymous complaints previously filed against the school principal. The Coroner found that, while this was partly caused by his being new to the job, the unsatisfactory staff handover arrangements also played a part. The Coroner recommends that during handover, new staff members should be informed of any special matters such as anonymous complaints and improvement plans related to the subject of complaint.

• Respect for staff’s personal time: The inquest heard that the then school principal would message her colleagues via WhatsApp even on Sundays. The Coroner recommends that TWGH issue guidelines to its schools’ management on respecting employees’ time off.

This inquest was widely covered in the press, including:

• (English reports) SCMP, The Standard;
• (Chinese reports) Apple Daily, Ming Pao.


Jeffrey Tam acted for the Hong Kong Professional Teachers’ Union, a properly interested person in the death inquest (Re Ms LAM Lai-tong 林麗棠, deceased, CCDI 206/2019).

Jeffrey Tam

Since being called in 2009, Jeffrey has established a solid practice in public law, having been involved in a number of landmark judicial review cases. Recently, in Tam Hoi Pong v Town Planning Board [2020] KCFI 2265, he represented the successful Applicant in challenging the Board’s decision to approve a developer’s application for planning permission even though the relevant requirements under the New Nature Conservation Policy were not met.

Jeffrey is also experienced in a broad range of civil work with an emphasis on land, probate, company and commercial law. He regularly represents both landlords and squatters in adverse possession cases. In terms of commercial cases, Jeffrey is frequently involved in shareholders’ disputes as well as securities and finance cases.

In September 2021, Jeffrey will act in the inquest into the deaths of two firefighters during the fire at Amoycan Industrial Centre, which housed 200 mini-storage units, in 2016.  He will be representing the relative of one of the deceased firefighters.


Disclaimer: This article does not constitute legal advice and seeks to set out the general principles of the law. Detailed advice should therefore be sought from a legal professional relating to the individual merits and facts of a particular case. The photograph which appears in this article is included for decorative purposes only and should not be taken as a depiction of any matter to which the case is related.