Coronial
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T and P - Non-inquest findings

Demographics

female

Coroner

Kirkegaard

Date of death

2016-11-01

Finding date

2020-05-06

Cause of death

Drowning

AI-generated summary

Two young sisters, aged 4 and 3 years, drowned in a residential swimming pool while unsupervised. Both parents were present in the home but inattentive—the mother was asleep in the bedroom while the father was using his computer, leaving the children unwatched for at least 20 minutes. The children gained access to the non-compliant pool through a faulty gate latch by climbing onto a trampoline positioned too close to the fence and using a chair from inside the house. Multiple pool safety breaches were identified despite a current safety certificate. The family had a prior child protection history involving domestic violence and concerns about supervision. Key preventability factors included: inadequate parental supervision, failure to maintain pool safety compliance, non-functional door locks, and unsecured access routes. The coroner emphasised the link between neglect, inadequate supervision, and accidental child death, recommending enhanced child protection worker training on accident prevention.

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

Specialties

paediatricsemergency medicinepathology

Error types

supervisionsystem

Clinical conditions

drowning

Contributing factors

  • Inadequate parental supervision
  • Children left unsupervised for at least 20 minutes while both parents inattentive
  • Non-compliant swimming pool with faulty gate latch
  • Trampoline positioned 410mm from pool fence (regulation minimum 900mm)
  • Lack of pool safety maintenance despite current certificate
  • Children's chair accessible as climbing aid
  • Broken rear sliding door lock not reported to landlord
  • Children unable to swim
  • No swimming lessons provided
  • Chaotic family circumstances and history of domestic violence
  • Prior child protection concerns regarding inadequate supervision

Coroner's recommendations

  1. Child protection workers in the department should be encouraged to develop knowledge about child accidental death to ensure they are thinking about child safety holistically and have an evidence-based understanding of links between neglect, inadequate supervision, and accidental death or injury of children
  2. Workers should be provided child accidental injury training and access to available child injury prevention resources such as those available through Kidsafe
  3. In situations of substandard housing, the department should consider utilising home safety inspection services to assess fire and safety hazards around the home and identify primary prevention opportunities
  4. Landlords or agents should be required to provide all tenants with instructions in relation to pool maintenance and compliance with pool safety certificates
  5. Regular compliance inspections should be mandated for landlords or agents to ensure pool safety compliance is maintained during tenancy
Full text
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Source and disclaimer

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