Finding into death of Emmerson Elizabeth Boyle
Deceased
Emmerson Elizabeth Boyle
Demographics
3y, female
Date of death
2014-09-02
Finding date
2016-02-17
Cause of death
Drowning
AI-generated summary
A 3-year-old girl drowned in a home bathtub after her mother briefly left the bathroom to retrieve a towel. The child had recently fallen twice and had a minor head cold but was otherwise healthy. She was found submerged after being left alone and climbed back into the bath for unknown reasons. Despite delays in emergency dispatch (7 minutes for nearest ambulance due to call-handling errors and software issues), effective CPR was initiated promptly by an off-duty firefighter neighbour. After 59 minutes of resuscitation, the child could not be revived. The death was accidental. Key lessons: supervision of young children near water is critical; emergency dispatch systems must function optimally; and paramedics on meal breaks should remain ready for Priority Zero calls.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Child left alone in bathroom
- Child re-entered bathtub unsupervised
- Unknown reason for submersion
- Possible disorientation from head cold
- Possible head injury from falls earlier that day
- Delay in emergency dispatch (7 minutes for nearest ambulance)
- Call-handling errors by ESTA
- Computer Aided Dispatch system software error
- Paramedics on meal break delayed departure from station (5 minutes)
Coroner's recommendations
- Five recommendations made by ESTA/IGEM directed at ESTA regarding call-taking and dispatch procedures; ESTA supported all recommendations and undertaken recommended actions
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