Finding into death of Child E

Contributing factors

• Lack of adult supervision for unspecified period while child slept
• Malfunctioning pool safety barrier and gate
• First pool gate did not automatically close or lock
• Second pool gate did not automatically close or lock and had become detached
• Broken bedroom window with open flywire screen allowing pool access
• Unlocked glass sliding door to dining room
• Property management inspection failed to detect pool gate damage on 30 March 2015
• Tenants did not report damaged pool safety barrier to property manager
• Poor maintenance of property including squalid living conditions
• Inadequate engagement by child protection services prior to case closure
• Mother living in unsuitable accommodation due to lack of alternative housing

Coroner's recommendations

1. During review of the Building Regulations 2006, the Minister for Planning consider adopting elements of Queensland's framework, including requiring that a pool safety certificate be obtained prior to a property with a pool being sold or leased.
2. The Minister for Planning consider the creation of a state-wide pool register to rigorously monitor compliance with pool safety regulations.
3. The Minister for Consumer Affairs, Gaming and Liquor consider that Consumer Affairs Victoria produce a pro forma Routine Inspection Report document which incorporates reference to 'pool fence and gate' and 'spa fence and gate', as in its condition report.