Deceased
E
Demographics
5y, male
Coroner
Clements
Date of death
2019-11-24
Finding date
2021-12-08
Cause of death
Hypoxic ischaemic encephalopathy due to near-drowning
AI-generated summary
A 5-year-old boy who could not swim drowned in a public aquatic centre after crossing from a shallow ramp area into a 1.2-metre deep main pool, unobserved by his parents. He was underwater for 90 seconds before being retrieved and resuscitated, but died from hypoxic-ischaemic encephalopathy. Critical factors included: parents' inability to read English or swim, lack of understanding of supervision requirements despite pictorial signage, no physical barrier between shallow and deep pools, and reliance on a 10-year-old child for communication with staff. Lifeguards responded appropriately (10-14 seconds) and initiated CPR. The coroner identified language barriers and lack of swimming skills in migrant families as preventable risk factors. A physical fence has since been installed.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
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