Finding into death of Baby LA
Deceased
Baby LA
Demographics
<1y, male
Date of death
2023-12-22
Finding date
2024-12-09
Cause of death
Hypoxic ischaemic encephalopathy due to an out of hospital cardiac arrest secondary to drowning
AI-generated summary
A 10-month-old boy drowned in a backyard fishpond after a 27-minute period of inadequate supervision. He was found unresponsive by his aunt and underwent prolonged resuscitation, suffering severe hypoxic brain injury. Despite intensive care management including neuroprotection, chest drain insertion for pneumothorax, and antibiotic therapy, he died from hypoxic ischaemic encephalopathy. The coroner emphasised that toddlers are curious and mobile yet lack understanding of water hazards. Critical lessons include: never assuming others are supervising; maintaining active, focused supervision around any water body; recognising that children can drown silently in seconds in shallow water; and securing or removing access to backyard water features, which currently lack mandatory safety regulations unlike pools.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- inadequate supervision of young child around water
- unsecured fishpond with removed grate
- adult caregiver distracted by phone and earphones while cooking
- lack of safety barriers around fishpond
- assumption that another adult was supervising the child
- child's age and developmental stage - mobile and curious but lacking understanding of water hazards
Coroner's recommendations
- Distribution of finding to Victorian Building Authority for consideration of regulating the building and design of fishponds to promote child safety
- Continued community education emphasising active supervision of young children around all types of water bodies
- Reminder that young children are at risk of unintentional drowning in all bodies of water, particularly in lead-up to summer season
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