Master K, a two-year-old, drowned in a hotel pool after falling from a step into the deeper adult pool section. He remained unnoticed underwater for over nine minutes while his mother was distracted by her mobile phone, despite being only two metres away. The coroner found inadequate supervision was the critical factor. Key clinical lessons: drowning can occur in seconds with minimal struggle; even brief lapses in constant visual supervision are dangerous; mobile phones and competing caregiving responsibilities create unacceptable distractions; children under five require arm's reach supervision; and older siblings cannot substitute for adult supervision. The case reinforces that constant, active, undistracted visual contact is essential around water, and that brief lapses in vigilance can have fatal consequences.
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