Inquest into the death of Kumanjayi Jurrah

Contributing factors

• no documented risk assessment for the pool excursion
• no clear allocation of supervisory responsibility to individual staff members
• failure to count children when exiting the pool facility
• inadequate supervision during changing procedures with multiple distractions (other children, visiting parent, staff confusion)
• child left locked inside pool complex after group departed
• delayed discovery of missing child (at least 5-10 minutes after exit)
• locked gate preventing immediate access to pool (at least 10-15 minute delay before CPR initiated)
• no emergency access protocol or spare key system in place
• no final sweep or visual check of pool by lifeguard
• inadequate staff training on supervision and excursion safety
• policies and procedures not formally implemented or accessible to staff in the community
• systemic failures in attendance documentation and child accounting
• poor management oversight of pool operations and implementation of prior safety recommendations

Coroner's recommendations

1. Engage expert mediation services to determine community and family concerns and restoration needs, and whether childcare and pool services can be restored
2. Consult with Royal Life Saving Northern Territory regarding any re-commissioning of Kintore Pool and properly consider and implement their recommendations
3. Conduct regular auditing by Royal Life Saving Northern Territory for all pools operated by MRC
4. Develop emergency management plans in consultation with Royal Life Saving Northern Territory to ensure access to swimming pools is possible at all times
5. Properly consider and implement recommendations from Royal Life Saving Northern Territory regarding auditing and emergency management
6. Ensure YMCA (contracted pool manager) is involved as appropriate in implementing recommendations
7. Ensure MRC has formal policies and procedures in place reflecting appropriate safety standards
8. Provide necessary training and guidance to Co-ordinators, Team Leaders and Educators to ensure safety standards are achieved in practice
9. Work proactively with Commonwealth department to implement recommendations regarding childcare services policies and procedures
10. Develop appropriate critical incident management policies and procedures for dealing with incidents such as this, including restorative procedures
11. Refer to Northern Territory Law Reform Committee the question of possible reform of s 182 of the Local Government Act 2019 (NT) to remove or amend immunity from criminal liability