Inquest Into The Manner And Cause Of Death Of Brett Ponting

33y · Male·Cerebral hypoxia caused by drowning

A 33-year-old man with severe intellectual disability and cerebral palsy drowned in a bath at a supported accommodation house. Carers left him unattended in the bath despite an Individual Plan stating 'full assistance required – two staff members needed'. Multiple staff had differing interpretations of this instruction; some believed supervision meant help preparing and removing the resident only, while others understood continuous bathroom presence was required. The coroner found the unsafe practice of leaving the resident alone in the bath had existed for years and was known to management but never addressed. Clinical lessons include: ambiguous safety instructions must be clarified and enforced; long-standing unsafe practices require investigation; supervision failures need escalation; duty of care must prioritise safety over perceived privacy rights; and management must actively enforce policies rather than rely on example or hope for change.