13 year old boy
Demographics
13y, unknown
Date of death
2021-04-08
Finding date
2024-02-26
Cause of death
Drowning
AI-generated summary
A 13-year-old child in state care died by drowning at Cedar Creek Falls on 8 April 2021. The coroner found that the youth worker Mr La's decision-making was reasonable, including not using physical restraint when the boys ignored directions not to swim in dangerous turbulent conditions. The death was found to be a tragic accident not caused by any individual's conduct. However, systemic gaps were identified: HSS lacked documented step-by-step risk assessment procedures for activities (only rectified post-incident); the Department had no standardized guidelines for service providers' risk assessment reporting; and Queensland Parks and Wildlife Service (QPWSP) lacked clear procedures for rangers to report hazardous water conditions or trigger park closures. Recommendations focus on standardizing risk assessment processes, implementing water safety training for residential care workers, and developing clearer risk management protocols and procedures for identifying when park areas should be closed due to dangerous conditions.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Turbulent water conditions at Cedar Creek Falls
- Lack of documented risk assessment procedures in service provider (HSS) at time of incident
- No standardized risk assessment guidelines between Department and service providers
- Absence of procedures for parks staff to report hazardous conditions or trigger closures
- Child ignored warnings and supervision directions
Coroner's recommendations
- Department standardize, through a guideline or documented risk assessment procedure, the process by which service providers are to assess and report to the Department on high-risk activities
- Department consider making it mandatory for out-of-home care service providers to provide water awareness safety training to their frontline staff
- QPWSP consider and action all accepted recommendations of the RLSSA report as soon as practicable, and include an oversight mechanism by which the QPWSP must monitor and evaluate the effectiveness of the implemented recommendations
- QPWSP attempt to enter into a memorandum of understanding or other information sharing agreement with Police in order to formalize the disclosure of information relevant to deaths or serious injuries occurring in national parks
- QPWSP introduce and implement a work method statement for rangers detailing the circumstances in which potentially risk conditions in relevant park sites should be reported to a supervisor, and the relevant actions that are to be undertaken if clear and identifiable risk thresholds are met
- DES form a working group to consider the implementation or amendment of policies to create a process of discovering potential problems and identifying appropriate solutions in relation to serious incidents or deaths involving visitors on QPWSP estates
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