Coroner's Finding: Pitt, Tallen John
Deceased
Tallen John Pitt
Demographics
4y, male
Date of death
2020-11-07
Finding date
2024-08-07
Cause of death
drowning
AI-generated summary
Tallen Pitt, a 4-year-old boy with speech delay, drowned in an unfenced 1.25-metre deep backyard swimming pool on 7 November 2020. The pool was purchased and installed without the legally required child-proof safety barrier. Tallen was an active, curious climber who could not swim. His mother was unavailable for supervision—either in the bathroom or asleep—when he gained access through an unlocked front door and open driveway gate. Early CPR by witnesses and paramedics could not revive him. The coroner found clear failures in pool fencing compliance and parental supervision. Key clinical lessons: young children (0-4 years) have the highest drowning risk in private pools; environmental barriers are critical when supervision lapses; and water safety requires active supervision, restricted access via barriers, swimming education, and emergency preparedness. The coroner endorsed Royal Life Saving's Keep Watch Program strategies.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- absence of child-proof pool safety barrier or fence
- unlocked front door permitting unimpeded access to pool area
- open driveway gate
- lack of parental supervision
- child unable to swim
- pool ladder inaccessible to child
- unsupervised access to water
- absence of owner compliance with National Construction Code pool safety requirements
Coroner's recommendations
- The State Government consider implementing legislation similar to NSW Swimming Pools Act 1992 which creates an offence for the owner of premises on which a pool is situated which is not surrounded by a child-proof barrier or fence
- The Brighton Council implement a program whereby pools within its municipality are checked to ensure compliance with the requirement to fence; all Councils ought to be implementing such a program
- The relevant State Government Department and each Council ought run an education program prior to summer each year which highlights the key messages of the Royal Life Saving's Keep Watch Program: Supervise, Restrict, Teach, and Respond, and also the legal requirements with respect to the fencing of pools
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