Inquest into the death of Jake Rhodes
Deceased
Jake Rhodes
Demographics
1y, male
Date of death
2015-01-17
Finding date
2018-02-27
Cause of death
hypoxic-ischaemic encephalopathy due to near-drowning
AI-generated summary
Jake Rhodes, a 21-month-old boy, drowned in a backyard swimming pool during construction before a Final Occupation Certificate had been issued. Contributing factors included: absence of supervision in moments before he entered the pool; absence of a functioning child-resistant barrier (temporary fence relocated onto pool coping with panel left open); and absence of the required life vest when he was found in the pool. Clinical lessons for educators: this inquest highlights systems failures in communicating pool safety requirements rather than acute clinical care. However, it demonstrates critical importance of prevention through proper supervision, barriers, and safety equipment. The coroner identified communication gaps between councils and pool owners regarding when pools can be used. Lessons include ensuring critical safety information reaches decision-makers directly, providing written rather than verbal instructions for safety-critical information, and maintaining effective barriers to prevent access to hazardous environments.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- absence of supervision in moments before pool access
- temporary pool fence relocated to pool coping, not forming continuous barrier
- fence panel left in open position, not properly secured
- absence of life vest when found in pool
- pool used before Final Occupation Certificate issued
- pool owner not directly informed of requirement to obtain Final Occupation Certificate before use
- unclear verbal communication regarding when pool could be used
Coroner's recommendations
- Ballina Shire Council to ensure correspondence relating to Complying Development Certificates for swimming pool construction, and all conditions relating to such certificates, are sent directly to swimming pool owners
- Narellan Pools Northern Rivers to include explicit written instructions within the Client Acknowledgement of the Pool Owner's Manual stating that a pool is not to be used until a Final Occupation Certificate has been issued by a consent authority, local council, or accredited certifier
- Minister for Innovation and Better Regulation to consider amending the Swimming Pools Act 1992 and Swimming Pools Regulation 2008 to provide for warning notices to be erected and maintained during swimming pool construction, stipulating that a swimming pool is not to be occupied or used until a Final Occupation Certificate is issued
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —