Two year old child - Non-inquest findings
Demographics
2y, unknown
Date of death
2013-12-14
Finding date
2014-09-09
Cause of death
Drowning in swimming pool
AI-generated summary
A two-year-old child died from drowning in a backyard swimming pool after immersion on 10 December 2013. The pool gate was tied open with rope, a practice known to adult household members including the child's mother. While the pool had non-compliance issues with fencing clearance zones, the primary failure was the open gate. The coroner identified inadequate adult supervision and non-compliant pool safety gates (particularly those held open) as the greatest risks to young children. No medical errors occurred; this was a preventable tragedy arising from environmental hazards and supervision failures in a household of 14 people including seven children.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- Pool gate tied open with rope
- Known practice of propping gate open by household members
- Inadequate adult supervision
- Pool fencing non-compliance with clearance zone requirements
- High child-to-adult ratio in household (7 children, 14 total residents)
Coroner's recommendations
- Ensure swimming pools are inspected and compliant with legislative safety requirements
- Address the practice of holding pool gates open to provide access for children
- Improve adult supervision of young children around pools
- Ensure pool fencing and gates comply with non-clearance zone requirements
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