Finding into death of Loi Ngoc Pham
Deceased
Loi Ngoc Pham
Demographics
48y, male
Date of death
2024-11-16
Finding date
2026-07-02
Cause of death
Drowning in the setting of recreational snorkelling
AI-generated summary
Loi Ngoc Pham, a 48-year-old man, drowned on 16 November 2024 while snorkelling for abalone off Altona Beach, Port Phillip Bay. Despite being a confident swimmer with one year's snorkelling experience, he was inadequately equipped: full wetsuit and heavy weight belt (5.2 kg) without fins, quick-release capability, or buoyancy compensation device. Found face-down after 2–3 hours in water, the autopsy confirmed drowning and did not exclude cardiac arrhythmia. This case exemplifies the tragic overrepresentation of South-East Asian communities in Victorian snorkelling drownings. The coroner emphasised critical safety improvements: high-quality quick-release weight belts, fins, appropriate buoyancy devices, and targeted safety messaging for culturally and linguistically diverse populations. Previous coroners had made similar recommendations following earlier drownings at the same beach, indicating ongoing failure to reach at-risk groups with water safety education.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- Absence of fins
- Weight belt without quick-release buckle
- Substantial wetsuit requiring heavy weights (5.2 kg total) creating buoyancy issues
- Inadequate buoyancy compensation device
- Snorkelling alone after friend exited water due to cold
- Cold water temperature (18°C) with no hood, gloves, or booties
- Possible undetected cardiac arrhythmia or seizure not excluded by autopsy
Coroner's recommendations
- Life Saving Victoria update public awareness messaging to include abalone fishing and promote through targeted education, social media channels, and relevant websites
- Life Saving Victoria work with recreational fishing organisations and agencies to include safe practices for abalone fishing
- Victorian Fisheries Authority update the Victorian Recreational Fishing Guide and resources to include abalone fishing safety and drowning risk information
- Weight belts used with wetsuits must be designed with ease of dumping as first priority, with buckles that release entire belt without catching
- Buckle profile must be manipulable even with heavily gloved fingers
- Swimmers must select high-quality weight belts with quick-release buckles and dump them without hesitation if in any difficulty
- All water safety organisations must regularly review effectiveness of safety messaging and programs to reach culturally and linguistically diverse populations
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