Coronial
NThome

Inquest into the death of Clinton Leslie Kingsley

Deceased

Clinton Leslie Kingsley

Demographics

2y, male

Date of death

1998-11-21

Finding date

1999-06

Cause of death

drowning

AI-generated summary

A 2-year-old Aboriginal boy drowned in an exposed septic tank at a remote community after plumbers removed concrete covers without installing replacements or notifying residents. The fibreglass lid's fastening screws had lost their threading through repeated use, rendering it ineffective. Plumbers believed the lid was secure but failed to adequately secure the tank before leaving the site. While the parents' supervision was appropriate for their community context, the death was avoidable with proper work practices: concrete covers should not have been removed before replacement covers were ready and installed. Key lessons include: never leave hazardous infrastructure exposed during maintenance, communicate clearly with residents about ongoing work, and design safeguards resistant to misuse in remote communities.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Error types

proceduralcommunicationsystem

Contributing factors

  • Removal of concrete septic tank covers without simultaneous installation of replacements
  • Fibreglass lid fasteners (self-tapping screws) lost threading due to repeated use over 2 weeks
  • Ineffective fibreglass lid that could be easily removed by a 2-year-old
  • Plumbers' failure to notify residents that work had commenced
  • Belief by plumbers that the fibreglass lid was secure when it was not
  • Septic tank misuse and maintenance issues requiring regular access

Coroner's recommendations

  1. Implement an education program in the community about proper use and maintenance of septic and sanitary systems
  2. Design septic tank systems and component parts to prevent them from being driven over or otherwise misused
  3. Ensure greater community involvement before and during capital works programmes in remote communities, including communication with residents about the nature of work and potential dangers
  4. Establish and maintain a register of accidents involving tradespeople on communities, to be managed by the Work Health Authority
Full text
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Source and disclaimer

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