Child at Rockhampton

Contributing factors

• Inadequate supervision of the child by accompanying adults
• Inadequate supervision of the inflatable device
• Inadequate risk assessment of inflatable device hazards by pool operator
• Child's lack of swimming competency
• Child's difficulty understanding and following instructions
• Absence of manufacturer's manual for inflatable device
• Single attendant supervising inflatable lacked clear line of sight to pool floor
• Attendant lacked lifeguard certification
• Staff multitasking diluted supervision effectiveness
• Inflatable device positioning and design created blind spots
• No formal risk assessment conducted before commissioning inflatable
• Lack of scenario training for staff on inflatable supervision

Coroner's recommendations

1. Pool operators must conduct risk assessments on inflatable devices before use, in accordance with RLSSA guidelines, incorporating manufacturer information. Staff training and competency assessment on resulting procedures should be mandatory, including scenario training. WPHS to supervise implementation.
2. AFlex Technology Ltd must ensure user manuals fully and prominently explain risks associated with inflatable devices, particularly drowning risk, and must provide manuals with each product.
3. WPHS to consult with industry and RLSSA to establish a Pool Industry Code of Practice as a Standard under the Workplace Health and Safety Act, providing guidance on risk management with effective monitoring and enforcement.
4. RLSSA to review and produce guidelines addressing: appropriate lifeguard qualification and accreditation levels required; required number of lifeguards at public and pay-for-entry pools; specific reference to pools using in-water obstructions including inflatable devices.
5. Australian Standards Committee to review AS3533.1 and AS3533.2 to include provisions regarding in-water inflatable amusement devices.
6. Department of Health, Local Government Association and RLSSA to conduct public awareness campaign reinforcing parental/carer responsibility for supervision at public pools.
7. Department of Health and RLSSA to develop program promoting enrolment of children and non-swimmers in learn-to-swim instruction including survival skills for sudden immersion.
8. RLSSA to review Keep Watch program to tie supervision recommendations to both age and swimming ability levels, with significant enforcement by pool staff and owners.
9. WPHS to consider legislation requiring all Queensland public pool operators to hold RLSSA membership to ensure compliance with safety guidelines.
10. Queensland Government to reconvene Queensland Water Safety Council with representatives from WPHS, Local Government Association, RLSSA, Queensland Injury Surveillance Unit and other parties, possibly under Commissioner for Children and Young People.
11. Local Government Association of Queensland and WPHS to provide public pool data to RLSSA and approved researchers.
12. State Coroner to improve availability of drowning information to approved researchers at early stage of coronial investigation to enable timely expert review and development of prevention strategies.
13. WPHS to improve efficiency of system for issuing Safety Alerts within short period after incident to protect public safety.
14. WPHS and QPS to develop protocol for after-hours WPHS contact; clarify and modify Memorandum of Understanding regarding coronial investigation; improve communication between WPHS and investigating police.
15. WPHS to ensure continuity of knowledge when investigator leaves investigation; ensure subsequent reports contain full incident details and safety alert/information dissemination is advanced timely.
16. WPHS to develop more instructive template/instructions for investigators preparing coronial reports, with reference to QPS practice.