Coronial
VIChospital

Finding into death of K S

Deceased

SK

Demographics

4y, female

Date of death

2021-01-15

Finding date

2023-11-08

Cause of death

Drowning

AI-generated summary

A 4-year-old girl from an Afghan refugee family drowned in Lysterfield Lake after entering the water during a brief lapse of supervision. She was unable to swim and had not received water safety education. Despite immediate CPR by bystanders and paramedics, she suffered devastating hypoxic brain injury and died two days later in ICU. The coroner emphasised that inadequate supervision is the common factor in nearly all young child drownings (16 of 17 cases reviewed). Key clinical lessons include: water safety education and swimming ability are critical, especially for culturally and linguistically diverse communities where drowning rates are 2.3 times higher; children under 5 require constant arm's-reach supervision near water; and even brief lapses of attention can be fatal. The case highlights systemic disparities in water safety knowledge among migrant populations.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Contributing factors

  • momentary lapse of supervision
  • inability to swim
  • lack of water safety education
  • cultural and linguistic diversity factors affecting water safety knowledge
  • brief unsupervised access to water

Coroner's recommendations

  1. Increased availability of water safety programs tailored to culturally and linguistically diverse (CALD) communities with low-level English and/or limited swimming ability
  2. Enhanced promotion of Royal Life Saving Australia's 'Keep Watch' program emphasising constant visual supervision of children in, on or around water
  3. Targeted water safety and swimming education for migrant and refugee families, particularly those from non-English speaking backgrounds
  4. Awareness-raising about the need for arm's-reach supervision of children under 5 near water at all times
Full text

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