Inquest Into The Death Of Kaled Kanj

Contributing factors

• child could not swim
• no flotation device worn
• mother supervising multiple children including infant
• overcrowded pool environment
• noise and visual obstructions in pool area
• difficulty of parent maintaining visual supervision in crowded conditions
• design features creating blind spots for lifeguards
• spa jets creating bubbles obscuring visibility

Coroner's recommendations

1. All public pools in the ACT must have an audit by the Royal Life Saving Society of Australia and implement audit recommendations
2. Risk assessments should be conducted especially during large numbers, with recommended minimum lifeguard ratio of 1:100 but adjustable based on facility-specific factors including weather, holidays, pool layout, surface reflection, attendance, user swimming capabilities, special needs, number and distribution of users, and recreational activities
3. Signage regarding parental/adult supervisor responsibility must be prominent in large lettering at entry, reception, and poolside, stating 'Children under 10 must be supervised by an adult at all times when in the aquatics area'
4. Signage regarding pool behaviour must be prominent at entry turnstiles and poolside
5. Educational pamphlets should be available at pool entry
6. Depth indicators should be displayed where depth changes with signage 'DEPTH INCREASES – 0.6 TO 1.2M PARENTS KEEP CHILDREN AT ARMS LENGTH'
7. Sufficient lifeguards should be provided to supervise all water areas without obstruction; blind spots and sun glare must be considered in lifeguard deployment
8. Where whirlpool entry is restricted by lane rope, signage should indicate closure: 'No Access beyond this point. Whirlpool Closed to Public: No Swimming in this area'
9. Consider recording every incident requiring lifeguard intervention
10. Set limits on number of users in different pool areas with effective monitoring
11. Deploy at least two lifeguards constantly moving between shallow and deep areas, with particular attention to non-swimming children
12. Highlight pool floor gradient changes with contrasting colour, particularly between toddler/leisure pool and deeper areas
13. Provide minimum four quarterly lifeguard training sessions covering emergency procedures, incident response, lifesaving skills, resuscitation, oxygen equipment, first aid, deep-water retrieval, special needs populations, public relations, and practical water work