Coroner's Finding: Amarni Dirani
Deceased
Amarni Dirani
Demographics
8y, female
Date of death
2006-12-15
Finding date
2008-10-24
Cause of death
Drowning
AI-generated summary
8-year-old Amarni Dirani drowned at Glenbrook Public Swimming Pool on 15 December 2006 during a school-organised celebration day excursion. The coroner found her death was preventable and resulted from multiple systemic failures. Critically, the school failed to correctly identify Amarni as a non-swimmer because her permission slip was ambiguously completed with unclear handwriting, causing her to be grouped with swimmers. Additionally, both the school and pool management failed to adequately supervise the inflatable obstacle course activity, with communication breakdowns preventing proper risk assessment. The pool also failed to assign a dedicated lifeguard to supervise the inflatable device despite its own guidelines requiring this. Although minimum staffing ratios were met, the coroner found that actual supervision on the day was inadequate for a child who could not swim. Key recommendations included implementing standardised coloured wristbands to identify swimmers versus non-swimmers and improving lifeguard-to-student ratios to 1:50 for primary school unstructured swimming activities.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Failure to correctly identify student as non-swimmer due to ambiguous permission slip completion
- Failure of school to comply with own risk assessment guidelines for swimming ability
- Breakdown in communication regarding inflatable device setup and supervision requirements
- Failure of pool to comply with own guidelines requiring dedicated lifeguard supervision of inflatable device
- Inadequate field of vision due to inflatable device obstruction of pool floor view
- Inadequate actual supervision despite minimum staffing ratios being met
Coroner's recommendations
- Implement standardised system of identifying swimmers and non-swimmers using coloured wristbands for all primary school students participating in unstructured swimming activities; wristbands to be obtained by schools and worn by students before arriving at the pool
- Royal Life Saving Society of Australia and NSW Department of Education & Training to adopt the policy of Blue Mountains City Council implementing a lifeguard-to-primary school student ratio of 1:50 for all unstructured swimming activities
- NSW Minister for Education to consider implementing school databases to record children's swimming ability, medical allergies, and other vital information relevant to duty of care
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 —