Case, Matthew Colin

Contributing factors

• inadequate parental supervision
• unaccompanied child entry to pool complex
• child left under supervision of 14-year-old sister only
• mother absent from pool for extended period
• child unnoticed transitioning from shallow to deeper pool
• pool design—no physical barrier between shallow children's pool and main pool
• pool operating in low patronage mode without dedicated lifeguard watching water

Coroner's recommendations

1. Minimum safety standards at public pools should be made enforceable by the Department of Industrial Relations implementing an appropriate code of practice or set of protocols, with the RLSS guidelines as a good starting point
2. Guidelines should be regularly reviewed, and a central database should be established to collate statistics of all significant safety-related incidents, with mandatory reporting system for such incidents
3. Workplace Health and Safety should redefine their involvement to spell out what operators need to do to achieve acceptable safety standards and conduct reviews to ensure compliance with their directions
4. Australian Standards for railing on disability ramps in public pools should be amended to require vertical bars to prevent persons slipping under the rail into deeper water
5. Minimum safety standards should include a requirement to regularly make head counts of people in the water and note the proportion of small children or weak swimmers, using this information to determine if a lifeguard or additional lifeguards should be on duty