Finding into death of LX
A 31-year-old man subject to a post-sentence supervision order died from mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen) at a residential facility. He was a vulnerable person with acquired …
Deceased
Kuti Abdurahman
Demographics
22y, male
Coroner
Coroner H C Alsop
Date of death
2010-11-22
Cause of death
Drowning
AI-generated summary
A 22-year-old Sudanese man drowned after inexplicably jumping from a jetty into Lake Narracan despite being unable to swim. The water was 2 metres deep with zero visibility, submerged obstacles, and thick mud. He entered panic and disappeared underwater. His companion, also a non-swimmer, attempted rescue but nearly drowned himself. Police officers searched for 20-30 minutes in dangerous conditions but could not locate him before his death. The coroner found his decision to jump into the water was inexplicable and the direct cause of death. No medical error or clinical intervention failure occurred. The coroner recommended improved warning signage about water hazards.
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FORM 38 Rule 60(2)
FINDING INTO DEATH WITHOUT INQUEST | Section 67 of the Coroners Act 2008 Court Reference: 4490/2010 In the Coroners Court of Victoria at Morwell
IH CH Alsop, Coroner having investigated the death of:
Details of deceased: : Surname: Abdurahman J / First name: Kuti Address: 23A Franklin Street MORWELL VIC 3840
without holding an inquest: find that the identity of the deceased was Kuti Abdurahman and death occurred on 22 November 2010 at Lake Narracan, Newborough from la) Consistent with drowning
Pursuant to Section 67(2) of the Coroners Act 2008, an inquest into the death was not held and the deceased was not immediately before the person died, a person placed in custody or care; but there is a public interest to be served in making findings regarding the following circumstances:
Mr Abdurahman was aged 22 at the time of his death. He was Sudanese and had been
living in Ausiralia for some four years.
On the 22nd November 2010, he arranged to spend the day with friends at Lake Narracan,
Newborough, arriving there at about midday.
At approximately 2.00pm several members of the group were in the water near the end of the public jetty. At this point, the water is some 2 metres deep. Signs in area display both written and diagrammatic warnings of “Shallow Water,” “No Lifesaving Devices,” “Submerged Obstacles”, and “Strictly No Diving.” The water is extremely cloudy to the
point that it is impossible to see any more than a few centimetres below the surface,
=
Mr Abdurahman was on the jetty with a friend, Kuka Adama. Neither Mr Abdurahman nor
Mr Adama could swim,
For some unknown reason, Mr Abdurahman jumped from the jetty into the water and immediately began to “thrash about” in an apparent panic. One of the group § suggested he
was “just joking around.”
The swimmers in the group left the water and called to Mr Abduraham to come over to the
jetty. At this point, he disappeared beneath the water.
Mr Adama, despite being a non-swimmer, jumped from the jetty in an attempt to rescue his friend. He immediately got into difficulties and-was rescued by one of the group, Ashley | j Bowden.
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Two police officers, Senior Constable Shane Kew and Constable Jeff Thorpe, attended the scene a few minutes later and immediately entered the water in an attempt to locate Mr Abdurahman.
Despite searching for 20 to 30 minutes in circumstances of serious danger to themselves,
they were uriable to locate him.
Mr Abdurahman’s body was later recovered by Search and Rescue Police. Mr Abdurahman’s inexplicable act of jumping into the water was the direct and sole cause of his death. ‘
Mr Adama cannot be criticised for jumping into the water. This was a spontaneous reaction to seeing his friend disappear. In entering the water he placed himself in immediate mortal danger. This action would probably have cost him his life if he had not been rescued by Ashley Bowden.
It is appropriate to acknowledge that both Senior Constable Kew and Constable Thorpe also placed themselves in danger in their efforts to locate Mr Abdurahman.
The depth of water, the existence of rabbish and other obstacles on the bottom of thick
mud, and zero visibility all combined to create a treacherous environment.
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SIGNAGE: The warning signs on and near the jetty refer to the hazards outlined above and infer that the primary danger is that the water is shallow. Pursuant to section 72(2) of the coroners Act 2008, I recommend that the City of Latrobe or other relevant authority with contro} over Lake Narracan and its environs, place a further warning sign in a conspicuous place on or near the jetty, informing the public that water conditions can mae : swimming
from the jetty dangerous.
I direct that a copy of this finding be forwarded to the Chief Commissioner of Police,
Signature: : i, A 74)
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