Finding into death of Amanda Bourke
Deceased
Amanda Bourke
Demographics
44y, female
Date of death
2018-01-18
Finding date
2018
Cause of death
Drowning
AI-generated summary
Amanda Bourke, aged 44, drowned at The Cutting beach in Tower Hill, Victoria on 18 January 2018. She and her fiancé entered the water despite warning signs and treacherous conditions including strong rips, undercurrents and variable depths. After approximately 20 minutes in waist-high water, she lost her footing, called for help, and disappeared beneath waves. A passing bystander rescued her but she had already inhaled water. Bystanders including a nurse performed CPR until paramedics arrived 21 minutes after the 000 call. The delay in emergency response was primarily due to location confusion (beach referred to as both 'The Cutting' and 'Killarney Beach') rather than clinical factors. Post-mortem showed drowning with minor injuries only. Clinical lessons include: the importance of clear emergency location identification at remote beaches; the hidden dangers of unfamiliar coastal areas to visitors; and recognition that poor signage compliance may contribute to preventable water safety incidents.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Treacherous sea conditions including rips, undercurrents and variable seafloor depth
- Lack of knowledge of local beach hazards by visiting swimmers
- Non-compliant warning signage that did not effectively communicate dangers
- Absence of emergency location marker codes at beach entry points
- Confusion regarding correct location in emergency services dispatch causing 21-minute delay to paramedic arrival
Coroner's recommendations
- Parks Victoria review warning signs along Belfast Coastal Reserve to ensure unique emergency marker codes are included where appropriate to prevent delays in emergency services response due to location confusion
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —