Finding into death of C K
Demographics
41y, male
Date of death
2017-12-21
Finding date
2019-07-21
Cause of death
Drowning
AI-generated summary
A 41-year-old man drowned at Skenes Creek Beach while swimming with his sons during a family holiday. He was a strong swimmer, as were his children who attended weekly swimming lessons. The death was unexpected and unnatural. The coroner's investigation focused on prevention opportunities rather than identifying clinical or medical mismanagement. Life Saving Victoria advised on systematic coastal hazard monitoring, risk assessment, and warning signage. The coroner recommended that the Marine and Coastal Council specify drowning prevention measures in Victoria's Marine and Coastal Policy in consultation with water safety experts, establishing clear responsibility for implementing and maintaining risk measures such as signage at beaches.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- Inadequate risk measures and warning signage at beach
- Lack of systematic coastal hazard monitoring
- Unclear responsibility for coastal safety management
Coroner's recommendations
- Marine and Coastal Council and Minister for Energy, Environment and Climate Change should specify in the upcoming Marine and Coastal Policy the risk measures to be put in place to prevent incidents of drowning amongst beachgoers throughout Victoria, including but not limited to signage. The identification and inclusion of suitable risk measures, and specification of responsibility for introducing and maintaining these measures, should be undertaken in consultation with industry experts and stakeholders such as Life Saving Victoria, forming regional and strategic partnerships where appropriate.
Full text
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 —