In the matter of four deaths by drowning in the Australian Capital TerritoryThe Inquest into the death of Najeebullah RafeeThe Inquest into the death of William Spencer HooleyThe Inquest into the death of Meredith Nancy HooleyThe Inquest into the death of Dinh Ta Nguyen

CORONER’S COURT OF THE AUSTRALIAN CAPITAL TERRITORY Case Title: In the matter of four deaths by drowning in the Australian Capital Territory The Inquest into the death of Najeebullah Rafee The Inquest into the death of William Spencer Hooley The Inquest into the death of Meredith Nancy Hooley The Inquest into the death of Dinh Ta Nguyen Citation: [2023] ACTCD 11 Decision Date: 30 June 2023 Before: Coroner Russell Decision: See [13], [29], [30], [41], [63] and recommendations at [71], [72] Catchwords: CORONIAL LAW – death in care – cause and manner of death – matter of public safety – drowning in inland waterways – water awareness and safety Legislation Cited: Coroners Act 1997 (ACT), s52 File Number

CD 287/2020 CD 345/2020 CD 346/2020 CD 17/2022 CORONER RUSSELL

1. The deaths of Najeebullah Rafee, William Spencer Hooley, Meredith Hooley and Dinh Ta Nguyen occurred within 16 months of each other. They each were caused by drowning in an ACT river, at locations promoted, inter alia, for water activities. There are matters of similar, but general, application raised in each case. For those reasons they are being considered together.

Najeebullah Rafee

2. Najeebullah Rafee died on 25 October 2020 at The Canberra Hospital, Woden. The cause of his death was drowning. Najeebullah was 23 years old at the time of his death.

He was born in Ghazni, Afghanistan on 1 January 1997 and was the oldest child of Sadeqa Rafee and Habibullah Rafee and the brother of Farishta and Zainullah. The family came to Australia in about 2014 as refugees from Afghanistan via Malaysia.

3. At the time of his death, Najeebullah was in his final year as a student at the Australian National University, studying international relations. He spoke Farsi, Dari and English.

He was clearly greatly loved by his family. He was a young man of significant promise, one of a strong group of friends at the University. Those friends, who called him Najeeb, have described him as a person who was ‘unconditionally kind’. Najeeb, they said, selflessly sacrificed so much of his life to support his family and friends, showing determination that was unparalleled. He had a gleeful zest for life and contagious laughter. Najeeb shared that he would have liked to have a family one day, and we know he would have been a great father. Najeeb put his values into action: just before his death he was awarded young Canberra Citizen of the Year for his longstanding volunteer work with refugee and migrant support services. We deeply miss him, and strive to honour his legacy and friendship through the Refugee and Migrant Swimming Program. If Najeeb were here today, we know he would be enthusiastically helping to run this life saving program.

Cotter Bend

4. Cotter Bend is part of the Cotter River Recreation Area and is at the junction of Paddys River and the Cotter River. It has a wide natural pool and sandy beach. There are walking tracks, barbeques, picnic areas and public amenities. ACT Parks describes the area, in its promotional material, as having ‘plenty of grassy areas with shade on sunny days’ with electric barbecues and toilets available. The public is, and was, in October 20201, encouraged to ‘[e]njoy a swim, splash and go fishing’ there.

Events of 15 October 2020

5. At about 4:15pm on Thursday, 15 October 2020 Najeebullah went to Cotter Bend with his mother, father and sister, Farishta. They were joined by his uncle and aunt, Faizullah and Rokshana Rafee, and their children.

6. As his uncle and aunt arrived, Najeebullah and his family were standing in the shallow part of the river. Faizullah, with his family, began to enter the shallows when Najeebullah walked out of the water and collected what Faizullah described as a “board, possibly blue in colour, of approximately 1m x 60cm” and re-entered the water.

I understand that Najeebullah intended to use that board as a flotation device. He asked Faizullah if he wanted to swim and if he knew how. His uncle said he did not know how to swim and remained at the side of the river with his children.

7. Najeebullah’s family have confirmed that he could not swim. It is more likely than not that, in deep water, Najeebullah lost control of the board. He was observed to get into difficulties and his father Habibullah, who could not swim, entered the water to try to help him but he, too, got into difficulties. Faizullah then entered the water to try to help but was himself at risk and, with the aid of his wife, who extended a stick, pulled himself back to shore. Habibullah had to be pulled out of the water. He seemed, to his brother, 1 As that observation relates to October 2020, it is accurate as far as I can determine from the data provided by the ACT Government agencies through the ACT Government Solicitor.

to be unconscious. Faizullah pushed on his chest and stomach and a lot of water came out of Habibullah’s mouth.

8. Farishta could not get mobile reception by the river and went to the road where she flagged down four men, who were employees of the Tidbinbilla Tracking Station. They entered the water to search for Najeebullah, while Farishta went on to the Cotter campground to obtain help. A camper offered to help, went to Cotter Bend and entered the water to assist with the search.

9. Najeebullah was located in about 3m of water about 3m from the riverbank, brought back to the shore and placed in the recovery position. It was estimated that Najeebullah had been underwater for about 20 to 25 minutes. Water trickled from his mouth. CPR was commenced by his rescuers. The ACT Ambulance Service and ACT Fire and Rescue arrived at the scene. Ambulance officers took over resuscitation efforts and transferred Najeebullah to The Canberra Hospital by ambulance.

Hospital

10. At the Canberra Hospital, Najeebullah was admitted to the intensive care unit and remained there for 10 days. He was placed on life support involving, inter alia, ventilation, dialysis and inotropic drug support. His injuries, however, were not survivable. He had sustained devastating and irreversible brain damage from the lengthy period without blood flow to his brain. Those injuries were confirmed by tests, including an electroencephalogram and magnetic resonance imaging. Life support was discontinued after consultation with his family and Najeebullah died a short time later, on the morning of 25 October 2020.

Post-mortem

11. A post-mortem examination by Professor Johan Duflou confirmed that the cause of Najeebullah Rafee’s death was drowning.

Hearing

12. I am satisfied that the manner and cause of the death of Najeebullah Rafee are sufficiently disclosed and that a hearing is unnecessary. The circumstances leading to his death were witnessed by family members and members of the public who sought to assist. Hospital and ambulance records and post-mortem findings are consistent with the statements of eyewitnesses.

Findings

13. Pursuant to section 52(1) of the Act, I make the following findings: i. Najeebullah Rafee died at The Canberra Hospital, Yamba Drive, Garran, in the Australian Capital Territory, on 25 October 2020.

ii. The cause of his death was drowning.

iii. That drowning was accidental.

William Spencer Hooley and Meredith Hooley

14. William Spencer Hooley was known by his middle name of Spencer. He was happily married to Kirsty McGovern-Hooley and they had two daughters, Morgan Vera Hooley

and Meredith Nancy Hooley. Meredith Hooley was their younger daughter. She was 11 years old at the time of her death. At that time her sister was 13 years old.

15. Mr Hooley is described by his family as having been a loving and engaged father and an intelligent and thoughtful person who enjoyed sharing his love of reading, music and science fiction with his daughters. He had a successful career as a Trademarks Examiner with IP Australia and was, his family said, recognised by his colleagues as always supportive and helpful.

16. Mr Hooley had a long history of medical problems, had been diagnosed with polymyalgia/fibromyalgia and was quite often in considerable pain. He was on medication for his conditions and, in the week of 19 December 2020, had been taking additional prednisone. He was said, by his family, to use cannabis occasionally as pain relief. He was described by them as being active but not ‘the fittest person in the world’.

17. Meredith and her sister had a history of developmental disorders, autism and attention deficit hyperactivity disorder, and suffered from anxiety. They received assistance through the National Disability Insurance Scheme (NDIS). Mr Hooley’s family said that he ‘showed up and actively participated in all therapy and school’ engagements for his daughters. He was cognisant of his daughters’ abilities and very protective of their welfare and safety. Ms McGovern-Hooley said that ‘as a rule neither of us would undertake new activities without careful planning, consideration, research and providing the support that [their daughters] needed to participate’.

18. His family say that Mr Hooley grew up around, and was experienced swimming in, country rivers, including the Gwydir River in Bingara and the Peel River in Tamworth.

Nonetheless, he was not ‘that physically strong’ and had been encouraged by his doctor to pursue very light swimming exercise.

19. Meredith and her sister had had swimming lessons when they were younger but did not continue them as they got older. Arrangements were in train, at the time of Meredith’s death, to recommence swimming lessons. The family regularly attended Tuggeranong Pool inter alia, to work on swimming skills and water safety. Their mother thought that they were “okay” in the controlled environment of the local swimming pool where they could stand up but did not know that that would be the case in a river where conditions may change suddenly. Mr Hooley had, in the past, taken them to other swimming spots such as Kambah Pool.

Tharwa Sandwash

20. Tharwa Sandwash is on the banks of the Murrumbidgee River, in Gigerline Nature Reserve. It is, and was in December 20202, described by Parks ACT as a picnic spot having ‘picnic tables and good access to launch a canoe’ and as a site for nature observation, birdwatching, swimming, walking and running, and watercraft.

2 As that observation relates to December 2020, it is accurate as far as I can determine from the data provided by the ACT Government agencies through the ACT Government Solicitor.

19 December 2020

21. On the afternoon of 19 December 2020 Mr Hooley took his two daughters to Tharwa Sandwash. Mr Hooley told his wife that he had found a new spot to try with the girls. It is for that reason that she believes it was the first time that they had been there.

22. It was not, Ms McGovern-Hooley said, planned as a swimming excursion but swimming costumes and towels were taken in the expectation that the girls might get wet paddling.

23. At Tharwa Sandwash, Morgan was collecting pebbles in the river and Meredith was with her. Their father was sitting on the bank. As they went further into the river the water became too deep, and Morgan returned to where she could stand, but she observed that Meredith was struggling. Morgan tried to help her but could not because she, herself, was being dragged down. She said that Meredith did not appear to be stuck on anything but was struggling in the deep water. Their father rushed into the water to get to Meredith. Morgan observed Meredith flailing and pushing her father underwater. She said he seemed to pass out and float back up. Morgan managed to get out of the water, shouted that she would get help and tried to phone for assistance but there was no mobile phone reception at the river side. She went to the car park where she could get mobile reception and rang for assistance. She sought the help of a man in the car park. He was able to identify the area more precisely for emergency services.

24. Morgan flagged down a woman who was driving into the Tharwa Sandwash carpark.

She entered the river and pulled Spencer to the edge of the river. Meredith could not be located. Police officers arrived at about 2:36pm and commenced cardiopulmonary resuscitation on Mr Hooley and searched the river for Meredith. Ambulance officers arrived shortly thereafter and took over resuscitation efforts which included advanced airway management to try to maximise re-oxygenation. Despite those efforts, Mr Hooley could not be revived. Meredith was located, in the river, about 150 to 200m away, and CPR was commenced. Meredith could not be revived and attempts to resuscitate her were ceased at 4:24pm.

Post-mortem

25. Post-mortem examinations were undertaken by Professor Johan Duflou, forensic pathologist, who confirmed that both Spencer Hooley and Meredith Hooley died from drowning. Toxicological testing revealed the presence of hydroxychloroquine, a treatment for polymyalgia/fibromyalgia, and evidence of the recent use of cannabis, in Mr Hooley’s blood. Professor Duflou was of the opinion that Meredith’s developmental disorders were significant conditions contributing to her death.

Morgan

26. It is clear that Morgan did all she could to assist her sister and her father. She had the presence of mind to seek help from the emergency services and from the woman driving into the car park. It was fortunate that she did not drown on that day. Had she remained in the water, in an attempt to help, that would very likely have made her father’s attempts to save her sister even more difficult and would have delayed any call to emergency services.

Mr Hooley’s knowledge of the danger

27. Mr Hooley’s family tell of a man who was careful and who would never knowingly expose his daughters to danger. It is their firm belief that Mr Hooley would not have let his daughters paddle in the water if he had known that the river at Tharwa Sandwash could be dangerous for those paddling.

Hearing

28. I am satisfied that the manner and cause of the deaths of William Spencer Hooley and Meredith Hooley are sufficiently disclosed and that a hearing is unnecessary. Morgan, Meredith’s sister and Mr Hooley’s daughter, was able to tell police what had happened.

The police arrived to observe Mr Hooley being brought to the river’s edge. They commenced to search for, and found, Meredith. Post-mortem findings are consistent with the statements of eyewitnesses.

Findings

29. Pursuant to section 52(1) of the Act, I make the following findings in respect of William Spencer Hooley: i. William Spencer Hooley died at Tharwa Sandwash, Tharwa in the Australian Capital Territory, on 19 December 2020.

ii. The cause of his death was drowning.

iii. That drowning was accidental.

30. Pursuant to section 52(1) of the Act, I make the following findings in respect of Meredith Hooley: i. Meredith Nancy Hooley died at Tharwa Sandwash, Tharwa in the Australian Capital Territory, on 19 December 2020.

ii. The cause of her death was drowning.

iii. That drowning was accidental.

Dinh Ta Nguyen

31. Dinh Ta Nguyen died on 22 January 2022 at Kambah Pool Recreation Area, Kambah.

32. At the time of his death, Dinh Ta Nguyen was 75 years old. He was born in Vietnam and lived in Hanoi with his wife and family.

33. In 2020 he travelled to Australia to visit his son, Hung Dinh Nguyen. The advent of restrictions associated with Covid-19 had the effect that, by the time of his death, he had not been able to return to Vietnam. He was staying with his son and his family in Canberra.

34. Mr Nguyen’s family believed that he was able to swim and “keep himself afloat”.

Kambah Pool

35. Kambah Pool is on the Murrumbidgee River in Canberra’s south. It is described by Parks ACT as a popular swimming and fishing area and is, and was in January 2022, promoted by Parks ACT as a site for birdwatching, fishing, mountain bike riding, swimming, walking and running, and watercraft.

22 January 2022

36. Mr Nguyen had been to Kambah Pool two or three times before 22 January 2022. On that morning he went to Kambah Pool with a number of people. He and his associate Nham Do set up fishing lines with Mr Do’s 14 year old grandson.

37. Shortly after midday, Mr Nguyen’s fishing rod slid into the water. He stripped to his underwear and entered the water to retrieve it. He walked into the water so far that only his head was visible. Mr Do stripped and waded into the water to assist. When he was waist deep in the water, Mr Do realised there was an undercurrent and became concerned as he was not a strong swimmer and would not be able to assist. A man kayaking in the area went to Mr Nguyen’s aid. He tried to extend the paddle of the kayak to Mr Nguyen so he could pull Mr Nguyen to safety but Mr Nguyen was already face down in the water and not swimming. He sank and did not reappear. The man in the kayak was not a strong enough swimmer to enter the water after Mr Nguyen. He, Mr Do and Mr Do’s grandson called out for help from people in the area, and several people called emergency services.

38. Police officers arrived at the river at about 12.28pm but were unable to see Mr Nguyen.

AFP Maritime Search and Rescue Units arrived at about 1.45pm. It was not until about 2.51pm that Mr Nguyen’s body was located submerged in 3 to 4 m of water about 25 m from where he was last seen. Police divers estimated the river temperature to be about 10°C. There had been heavy rain in the area and water levels were somewhat higher than normal.

Post-mortem

39. A post-mortem examination was conducted by Professor Johan Duflou, forensic pathologist, who confirmed that the cause of Dinh Ta Nguyen’s death was drowning.

Toxicological testing revealed what was described as a modest quantity of alcohol in the blood (0.020 g/100ml).

Hearing

40. I am satisfied that the manner and cause of the death of Dinh Ta Nguyen are sufficiently disclosed and that a hearing is unnecessary. The circumstances leading to Mr Nguyen’s death were witnessed by those who were with him and those who sought to assist. Post-mortem findings are consistent with the statements of eyewitnesses.

Findings

41. Pursuant to section 52(1) of the Act, I make the following findings: i. Dinh Ta Nguyen died at Kambah Pool Recreation Area, Kambah, in the Australian Capital Territory on 22 January 2022.

ii. The cause of his death was drowning.

iii. That drowning was accidental.

Matter of Public Safety

42. I am required, by Section 52 (4)(a) of the Act, to state whether a matter of public safety is found to arise in connection with an inquest and, if so, comment on the matter.

43. The locations at which these drownings occurred are promoted by the ACT Government as places for river-based recreation. It is a part of their beauty and attraction that these environments are inherently not as predictable or regulated as man-made recreational structures.

44. An essential part of the overall management of such sites is an appropriate and balanced consideration of the risks posed by activities promoted at them.

Royal Lifesaving Society – Australia Aquatic Safety Assessment

45. The Royal Life Saving Society - Australia (RLSSA), a specialist agency in aquatic risk management, has conducted a 10 year study, covering the period 2011/12 to 2020/21, entitled Drowning in Rivers, Creeks, Lakes and Dams. The analysis revealed that 924 people drowned in inland waterways during that period, that 73% of those drowning deaths occurred in rivers or creeks, and that 40% of the drowning deaths occurred within 20 km of where the person lived. The study includes the Murrumbidgee River in the ACT as one of the five worst locations for drowning deaths. In the period covered by the study, 15 drowning deaths occurred in inland waterways in the ACT. The authors of the report conclude that [m]any people are unaware that inland waterways are a leading location for drowning deaths in Australia.

46. In addition to Australia-wide studies on the risks of drowning in inland waterways, the RLSSA has undertaken an Aquatic Safety Assessment of the Cotter Recreation Reserve. That assessment was done in September 2022. It specifically includes an assessment of Cotter Bend but many of the observations made are relevant to Tharwa Sandwash and Kambah Pool.

47. With respect to river environments, the assessment notes the general proposition that, [t]he flat, still surface of an inland waterway can give a false sense of security and often hide features and conditions such as currents, undertows, or submerged objects, making them potentially dangerous. Conditions in our inland water environments can change unexpectedly, and … can lead to severe consequences for the unprepared.

48. Risks canvassed by the RLSSA, with respect to the Cotter Recreation Reserve, but with more general application, and which apply in the cases of Najeebullah Rafee, Spencer and Meredith Hooley and Dinh Ta Nguyen, are that people can find themselves in trouble in deep water, because they don’t appreciate that the depth of the water can change suddenly, because they fall and can’t recover, because they are dragged by strong currents or because they overestimate their ability. Weak swimmers, in such circumstances, can be swept downstream or pulled under the water.

Warnings by Parks ACT

49. The current Parks ACT websites with respect to each of the locations, after describing the site and potential activities, have a section headed Before you go/How to get there.

It is in the same terms for each site and invites people to Prepare by:

• understanding safety

• checking alerts

• checking water quality before swimming

and carries a reminder that mobile phone reception may be unreliable. There is a hyperlink, accessed by clicking on the word safety. The user is told, then, that Parks and reserves are natural environments that can be unpredictable. It lists a number of ways ‘to reduce risks and stay safe’ including: check the water - check whether swimming is allowed at the location, check the water quality (in relation to bacteria and blue-green algae), check the flow and depths, and do not enter the water if signs advise of hazards.

As at 22 January 2022, Parks ACT website warning was relevantly in the following terms:

• Check the swimming conditions signs located at each recreation area.

• Do not enter the water if signs advise that conditions or water quality are unsafe.

• Watch the flow! Shallow moving water is stronger than you think.

• Always supervise children carefully whenever they are in or near the water.

• Never dive into any part of the river because there may be rocks or submerged trees.

50. Information provided by the relevant ACT Government agencies does not permit me to determine with precision the content of those warnings on cognate websites as at 25 October 2020 and 19 December 2020.

51. The website warning as at January 2022, it would appear, was more informative as to risks of swimming and paddling than the current Parks ACT website.

Signage

52. At each of the locations there is, and was at the relevant times, at least one clearly visible sign, headed Notice to Swimmers. A symbolic exclamation mark introduces a warning message:

• Be advised that there are no life-saving services, facilities or resources available at this location.

• Visitors are reminded that although your well-being is our concern, it is your responsibility.

• PLEASE TAKE CARE.

53. The sign, in both symbolic and written form, indicates the hazards which may be encountered. The hazards identified are strong currents, shallow water, slippery, uneven ground, steep access, wildlife.

54. At Kambah Pool and at Cotter Bend, there is a further category of sign, headed ‘Public Notice’, containing the following information: Rivers may look safe but are often dangerous. Cold water in rivers can be lethal.

Watch the flow! Flowing water is stronger than you may think. Check for submerged objects. Never dive into any part of the river. Always supervised children.

55. At Kambah Pool, a further category of sign advises: Enter the river at your own risk. Strong currents, submerged objects and contaminated water may be present.

56. A further notice at Cotter Bend advises that there are no lifesaving services.

57. There is no basis on which to criticise the number, type or content of the signs on display at the three locations, but it is difficult to assess the effect that those signs might have on people who are already at the river for recreation. People who have arrived at a location, set on an activity, may well be difficult to dissuade from that activity.

58. In Najeebullah Rafee’s case, a family outing had been arranged at the river. In the cases of Spencer and Meredith Hooley and Dinh Ta Nguyen the purpose of the visit to the river was not to swim, but they found themselves in water of a depth or strength with which they couldn’t cope. Meredith was wading in the water, picking up pebbles with her sister. Mr Nguyen was attempting to retrieve his fishing rod.

Knowledge of the dangers

59. Najeebullah Rafee, who could not swim, entered the water with a board used as a flotation device. For a non-swimmer the use of a flotation device of that kind, in water of variable depth, carries significant risk, particularly if the grip on the board is released.

I am satisfied that Najeebullah very significantly underestimated the dangers posed by the river.

60. I am satisfied that Spencer Hooley did not sufficiently appreciate the dangers posed to his paddling daughters by the Murrumbidgee River at Tharwa Sandwash.

61. I am satisfied that Mr Nguyen did not realise the danger posed by the undercurrent either alone or in combination with the temperature of the water at Kambah Pool when he attempted to retrieve his fishing rod.

Risk to those attempting to help

62. Both Najeebullah’s father and his uncle entered the water in an attempt to help. Neither of them could swim and both got into difficulties. Habibullah Rafee was at serious risk of drowning.

63. Spencer Hooley entered the water in an attempt to save his daughter and drowned in that attempt.

64. Nham Do entered the water in an attempt to help Mr Nguyen and realised the current was too strong for him. A kayaker attempted to help Mr Nguyen but he himself was not a strong swimmer.

Need for enhanced public awareness

65. I am satisfied that, in each case, despite the signage at the river, there was a lack of understanding of the danger the river posed, and that, in connection with each inquest, a matter of public safety arises. That matter of public safety concerns the need for

enhanced education and awareness programs aimed at the general community and at specific groups, including culturally and linguistically diverse communities who may be even less familiar with the risks posed in the ACT waterways, particularly in waterways promoted for recreation, swimming, fishing and watercraft.

66. The RLSSA considers that ‘water safety awareness and education programs to local members of the community and user groups have not been promoted by the ACT Government’. The report itself does not provide an analysis of ACT Government water safety awareness and education programs, or lack thereof. I do not, therefore, adopt that RLSSA opinion. I note that the ACT Government has advised that it ‘facilitates’ an ‘Aqua Safe’ program for all year 2 students in public schools to teach water safety knowledge and awareness and provides funding for swimming programs, to the RLSSA to support varied refugee and migrant swimming programs and to Muslim Sister to Action to support their female swimming programs.

67. I am satisfied that Najeebullah Rafee and his family, Spencer Hooley and Dinh Ta Nguyen were not, or were not sufficiently, aware of the risks posed by the rivers at Cotter Bend, Tharwa Sandwash or Kambah Pool. Inter alia, the RLSSA recommends both general and ‘targeted’ ‘[p]ublic education and safety awareness program[s] outlining known and likely to occur hazards’ and promoting ‘safe behaviour around water within the local community’.

68. I recommend that the relevant agencies of the ACT Government develop enhanced general, and targeted, public education and safety awareness programs which publicise the risks of river activities and promote an understanding of the dangers posed by rivers, particularly for those who are not strong swimmers.

Publicly accessible rescue equipment

69. The RLSSA notes the absence of publicly accessible rescue equipment located in proximity to the Cotter Bend swimming area and suggests that, at a minimum a life ring/flotation device or throw rope should be available at the location. There were no such devices at Tharwa Sandwash or Kambah Pool. While the evidence does not permit me to find that the absence of a life ring/flotation device or throw rope at any of the locations contributed to the deaths of Najeebullah Rafee, Spencer and Meredith Hooley or Dinh Ta Nguyen, it is possible that the presence of such a device, if readily accessible, may have led to a different outcome in one or all cases.

70. In response, the ACT Government has stressed the need for persons to exercise responsibility for their own safety and that of others accompanying them, including children and pointed to, what it says is, ‘the high risk of vandalism, interference, theft and misuse’ of such equipment, if installed. In addition to that, it points to the fact that the Territory is limited by the financial and other resources available to it and there are significant ancillary costs including those associated with providing appropriate storage, the need for additional signage providing instructions as to the use of the equipment, regular inspections by Territory employees, maintaining and (in view of the risks of vandalism, interference theft and misuse) replacing any equipment which is installed.

71. I accept that those are real and significant concerns, which I cannot dismiss and am not, therefore, in a position to recommend that the ACT Government install such equipment at Kambah Pool, Cotter Bend or Tharwa Sandwash, or other places at which rivers might be accessed. However, I do recommend that the relevant agencies of the ACT Government consult with the RLSSA with a view to determining whether there is any type of rescue equipment which it would be feasible to place at popular riverside locations.

Phone coverage

72. Those attempting to assist could not obtain phone coverage at the riverside, at Tharwa Sandwash or Cotter Bend. Morgan had to walk to the carpark at Tharwa Sandwash to call emergency services. Her call commenced at 2.18pm. Police arrived at the scene some 18 minutes later and ambulance officers shortly thereafter. The emergency call with respect to Najeebullah Rafee was received at 5.03pm, was noted as time critical.

Ambulance officers, the first emergency service to arrive, arrived at the scene at 5.15pm and were with the patient at 5.18pm. Given the distances to be covered, it necessarily took some time for emergency services to arrive at each of those locations after being notified of the emergency. In those circumstances, noting the time-critical nature of assistance to those at risk of drowning, I cannot conclude that the lack of phone coverage at the riverside contributed to the deaths of Spencer and Meredith Hooley or Najeebullah Rafee.

73. The McGovern-Hooley family have raised the possibility of introducing smart technology hubs to those environments. This, I understand, is a reference to, what is canvassed in the RLSSA’s Aquatic Safety Assessment of the Cotter Recreation Reserve as, one of a range of, what it calls, ‘risk treatment options’. The ‘smart technology’ described integrates CCTV, microphone capabilities and artificial intelligence’. As I understand it, such equipment would enable communication with emergency services. I have no information about how intrusive such equipment might be into the natural environment. In the context of these proceedings and on the evidence available to me, it is not appropriate for me to make any recommendation that such equipment should be installed, and I note that the allocation of resources is a matter for government. However, consideration of the desirability and feasibility of such equipment could form part of any consultation between the ACT Government agencies and the RLSSA recommended at paragraph 75 of these findings.

Recommendations

74. That the relevant agencies of the ACT Government develop enhanced general, and targeted, public education and safety awareness programs which publicise the risks of river activities and promote an understanding of the dangers posed by rivers, particularly for those who are not strong swimmers.

75. That the relevant agencies of the ACT Government have discussions with the RLSSA with a view to determining whether there is any type of rescue equipment which it would be feasible to place at popular riverside locations.

Closing remarks

76. Najeebullah Rafee was a young man of considerable achievement, at the dawn of his adult life. He was clearly greatly loved by his family and loved and admired by his friends who, have described his kindness, zest for life and contagious laughter. Inspired by his memory, his friends have committed themselves to the Refugee and Migrant Swimming Program.

77. Spencer Hooley was a loving and engaged husband and father, actively involved in his daughters’ lives. He had a successful career. His daughter, Meredith, was only 11 years old at the time of her death. Both are greatly missed by Spencer’s wife and Meredith’s mother, Kirsty McGovern-Hooley, and their daughter and sister, Morgan, as well as by their wider family. Ms McGovern-Hooley and her family have been strongly involved in the coronial process and have thought deeply about, and advocated for, improvements in water safety.

78. Dinh Ta Nguyen was visiting his son in Australia. It is clear that he was loved by his family in Australia and Vietnam.

79. The loss of these four lives has been immeasurable to their families and friends. I extend my condolences to all of them.

I certify that the preceding seventy-nine [79] numbered paragraphs are a true copy of the Reasons for Decision of her Honour Coroner Russell.

Legal Officer: Simone Richards Date: 30 June 2023