Coronial
QLDhome

T, a child aged 15 months

Demographics

1y, male

Coroner

Lock

Date of death

2015-03-21

Finding date

2015-12-18

Cause of death

Hypoxic ischaemic encephalopathy due to drowning

AI-generated summary

A 15-month-old child drowned in a partially-filled, unmaintained home swimming pool after the entrance gate was propped open with a length of wood. The child was playing in the yard while his mother's attention was occupied changing a flat car tyre nearby, approximately 20 metres away. Despite the child having received swimming lessons, he likely fell, struck his head, and became unconscious in the shallow 31cm water. Approximately 5-10 minutes elapsed between last sighting and discovery. The coroner found the death preventable, emphasising that pool gate propping—a deliberate breach of pool safety legislation—renders compliant fencing ineffective. Key clinical lessons include: vigilant supervision of young children around water is non-negotiable, physical barriers alone are insufficient without maintenance and compliance, and even brief lapses in supervision with breached access controls create fatal risk. Early CPR and hospital resuscitation achieved return of spontaneous circulation but hypoxic-ischaemic brain injury was irreversible, highlighting that prevention remains paramount.

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

Specialties

paediatricsemergency medicineintensive carepathology

Error types

supervisionsystem

Clinical conditions

drowninghypoxic ischaemic encephalopathyhypoxic brain injury

Procedures

cardiopulmonary resuscitationendotracheal intubationadvanced resuscitation

Contributing factors

  • pool gate propped open with wood
  • lapse in supervision
  • adults' attention focused on repairing vehicle tyre
  • unplanned visit - child not regular visitor to property
  • poor communication of supervision responsibility between adults
  • partially filled but untreated pool with unclear water visibility
  • shallow depth (31cm) but still sufficient for drowning risk

Coroner's recommendations

  1. Endorse efforts of Hannah's Foundation to raise public awareness about pool safety, particularly the 'STOP! DON'T PROP' campaign
  2. Emphasise that pool gates must never be propped open and must be checked to ensure correct closure
  3. Promote vigilant supervision of young children around water as essential prevention strategy
  4. Consider review of pool inspection regime and training of pool safety inspectors, noting concerns about efficacy
  5. Await completion of State Government Inter-departmental Committee for Pool Safety review, which is examining immersion incident reporting, pool safety management plans, inspector training, and potential new criminal offences for intentional breaches of pool safety legislation where death or serious harm occurs
Full text
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Source and disclaimer

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