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Two year old child - Non-inquest findings

Demographics

2y, unknown

Coroner

Clements

Date of death

2013-12-14

Finding date

2014-09-09

Cause of death

Drowning in swimming pool

AI-generated summary

A two-year-old child died from drowning in a backyard swimming pool after immersion on 10 December 2013. The pool gate was tied open with rope, a practice known to adult household members including the child's mother. While the pool had non-compliance issues with fencing clearance zones, the primary failure was the open gate. The coroner identified inadequate adult supervision and non-compliant pool safety gates (particularly those held open) as the greatest risks to young children. No medical errors occurred; this was a preventable tragedy arising from environmental hazards and supervision failures in a household of 14 people including seven children.

AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.

Contributing factors

  • Pool gate tied open with rope
  • Known practice of propping gate open by household members
  • Inadequate adult supervision
  • Pool fencing non-compliance with clearance zone requirements
  • High child-to-adult ratio in household (7 children, 14 total residents)

Coroner's recommendations

  1. Ensure swimming pools are inspected and compliant with legislative safety requirements
  2. Address the practice of holding pool gates open to provide access for children
  3. Improve adult supervision of young children around pools
  4. Ensure pool fencing and gates comply with non-clearance zone requirements
Full text

OFFICE OF THE STATE CORONER NON-INQUEST FINDINGS OF THE INVESTIGATION INTO THE DEATH OF A TWO YEAR OLD CHILD CITATION: Investigation into the death of a two year old child TITLE OF COURT: Coroner’s Court JURISDICTION: Brisbane FINDINGS OF: Ms Christine Clements, Deputy State Coroner CATCHWORDS: CORONERS: death of a child, drowning in swimming pool, lack of supervision, failure to close pool gate.

A two year old child died on the 14 December 2013 following an immersion in a backyard swimming pool which occurred on the 10 December 2013. The immersion occurred at a rental property. The house was occupied by 14 people inter-connected as family members and including seven children.

At the time of the immersion incident, the pool was not compliant with relevant legislation with respect to clearance zones around the barrier fencing to prevent children from climbing the fence or digging underneath it or being able to reach the safety lock.

However, on the facts in this matter, none of these deficiencies were relevant to the circumstances in which the two year old entered the water. It was clear on the evidence that the pool gate had been temporarily secured in an open position by means of a rope. This action was said to have occurred due to some of the children in the household tying the gate open.

However, there is little doubt that the adult family members of the extended household were aware of the continuing practice that the gate was ‘propped open’ in some manner or another to enable easy access for the children.

Sadly, it was also known to the child’s mother that the pool gate ‘was always open when I had been there before. Sometimes it is shut, but it was hardly ever shut. It was normally propped open with rope.’ In all these circumstances, it is unlikely that the police will pursue charges with respect to the death of the child.

There is little benefit to be gained by an inquest in these circumstances.

While the pool was strictly non-compliant with respect to certain details of the fencing and non-clearance zones, the greatest failing was with respect to the failure to close the pool safety gate which was tied in an open position.

The relevant Council has ensured that the swimming pool has been inspected, assessed and re-certified as compliant with legislative requirements for safety after maintenance works were performed.

An inquest is unlikely to make any difference in helping to prevent the deaths of other children occurring in similar circumstances.

The greatest risk to non-swimming children remains inadequate adult supervision together with non compliant fencing and gates, especially allowing gates to be held in an open position.

Christine Clements Brisbane Coroner 9 September 2014 Findings of the investigation into the death of a two year old child 1

Source and disclaimer

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