Coroner's Finding: TRINH Crystal

Contributing factors

• non-compliant double gates without self-closing mechanism
• gates left unsecured and open on the day of drowning
• failure by pool owner to rectify identified non-compliance
• inadequate Council inspection procedures and lack of follow-up
• failure to specify completion date for rectification work
• inadequate oversight by Department for Education during accreditation process
• absence of supervision of child at pool area
• pool inflatable slide obscured child's location in water

Coroner's recommendations

1. Make findings available to Chief Executive Officers of all Local Government bodies in South Australia and the Board of Directors of the Local Government Association of South Australia
2. Draw to the attention of all Local Government bodies the remedial measures implemented by City of Salisbury, including the Pathway system for monitoring pool compliance inspections and follow-up
3. Implement specified completion dates for all pool rectification work, not leave completion dates blank
4. Establish reliable systems for follow-up inspection of non-compliant pools with designated building officer responsibility and electronic tracking
5. Activate enforcement procedures if non-compliant features are not rectified within specified timeframe
6. Develop uniform standards across South Australian councils for inspection requests and building inspections including swimming pools
7. Department for Education should require independent certification from approved authorities that pools at family day care premises comply with safety requirements