Coroner's Finding: Shannon Abby-Rose Rankin
Deceased
Shannon Abby-Rose Rankin
Demographics
11y, female
Date of death
2006-03-25
Finding date
2010-02-16
Cause of death
Drowning following entrapment on the active main drain of the spa pool
AI-generated summary
An 11-year-old girl drowned in a spa pool at a residential apartment complex after becoming entrapped on an active main drain filter. The drain had been completely blocked during construction by cement, aggregate, and other material that entered the drain during pebblecreting work when proper preventive procedures were not followed. The blockage created approximately 350kg of suction pressure that trapped the child beneath the water surface. Multiple system failures allowed this preventable death: a design decision to locate the active drain in the floor of the spa (unusual and more dangerous than wall-mounted drains), failure to prevent construction debris from entering the drain, failure to conduct comprehensive safety assessments and independent testing before the building was opened for occupation, and an inadequate regulatory system that permitted self-certification without independent expert verification. The coroner found no evidence that anyone knew of the danger beforehand. Recommendations were made to prohibit active main drains in spa floors, require independent expert certification of pool and spa safety before handover, ensure occupation certificates for developments with pools confirm safety compliance, and inform the public of the dangers of active main filter drains.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- Active main drain installed in floor of spa pool
- Complete blockage of main drain caused by cement and aggregate material entering during pebblecreting
- Failure to prevent entry of construction material into drain during pebblecreting work
- Failure to adequately test plumbing for blockages after construction
- Failure to conduct comprehensive safety assessment of spa before handover
- Self-certification by pool builder without independent verification
- Lack of independent expert inspection of pool/spa safety before issue of Occupation Certificate
- Inadequate regulatory framework allowing pools/spas to be used without safety certification
Coroner's recommendations
- Action be taken to prohibit the inclusion of an active main filter drain in the floor of spa pools in future constructions
- Media action be taken to inform the public as to the potential dangers associated with active main filter drains in the floor of spa pools
- Action be taken to require the certification of pools and spas as being in compliance with statutory and other building requirements and as being safe for proposed use by an appropriately qualified and independent expert prior to the pool or spa being handed over for use by occupants
- Action be taken to ensure that where a pool and/or spa forms part of a property development an occupation certificate not be issued by the relevant Principal Certifying Authority unless and until that Authority has satisfied themselves that the pool or spa has been constructed in accordance with relevant statutory and other building requirements and is safe for proposed use
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