Finding into death of Jimmy Nguyen

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: 6016/09

FINDING INTO DEATH WITHOUT INQUEST

Form 38 Rule 60(2) Section 67 of the Coroners Act 2008

I, HEATHER SPOONER, Coroner having investigated the death of JIMMY NGUYEN without holding an inquest:

find that the identity of the deceased was JIMMY NGUYEN

born on13 October, 1994

and the death occurred on 29 December 2009

at Royal Children's Hospital, 50 Flemington Road Parkville VIC 3052

from: la, CONSISTENT WITH DROWNING

Pursuant to Section 67(2) of the Coroners Act 2008, I make findings with respect to the following circumstances:

1. Jimmy was just 15 years old when he died. He was a student and lived with his family at 20 Erin Street Deer Park. A friend described him as previously healthy. !

2, A police investigation was conducted into the circumstances surrounding the death, The death was also reviewed by Coroners Prevention Unit (CPU). 2

3. It was apparent that on 29 December, during the 2009 summer school holidays Jimmy went to the South Melbourne Beach with a group of about 25 friends to celebrate the birthday of William Wong.

They arrived between about 2. 00-3. 00pm and located themselves on the beach about 100 metres west of the South Melbourne Life Saving Club. Whilst the day had apparently started off sunny, one of Jimmy's friends, William Wong, indicated that it became dark later in the day and that "the water was cold and pretty rough. The waves seemed big..." 3

' Siaiemont of William | ~ (fhe Coroner for coroners created to sirengihen their prevention role and provide fhom with prag a public heath and satety,

3 Statement of Willi

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4, At about 4.00pm Jimmy and some of the group went swimming in the water after possibly drinking half a stubby of beer and consuming fish and chips that others had obtained from some nearby shops. According to the statement of William Wong,

"Me and my ve mates went in to the water and were swimming jr at least 30 minutes. We stayed in our group and I remember we were talking and laughing while we were in the water.

The water was above our heads and we were a fair way out. Jimmy was out there with us too.

Jimmy is not a good swimmer and told me he coulda t swim and because it was rough we were all struggling in the water.

Afer about half an hour one of my mates started drowning and we went to help him, then we all started struggling and decided to go back to shore.

When we all got out of the water Jimmy was with us and I decided to go and get changed. Some of my mates came with me.

I got changed and then one of my mates came in and said someone had drowned. Afer about fve minutes we realised it was Jimmy.

I don't know why Jimmy went back in to the water and no one saw him go, but he definitely came out of the water with us on to the beach before I got changed.

Jimmy was healthy fom what I remember. He was never sick and didn't have asthma when I knew him. He was very happy at school and loved a laugh. Im not sure but I think he was happy at home.

As far as Iam aware Jimmy never used drugs and the alcohol he had wouldn't have affected him on this day.

When we were swimming there were no fags up but there were a fw people on the beach, but not many in the water.

T have no idea why Jimmy went back in. We were ail worn out fromstruggling in the water."

5. A short time later two passing witnesses observed Jimmy face down in waist deep water. They initially approached him thinking it was a game however when they realised he was in trouble they attempted to drag him from the water and called for assistance. Several beach goers came to his aid and two of them commenced CPR.

6. Assistance was also sought from the Lifesaving Club and lifesavers who were siill there after

who had been votified of the incident

hours provided CPR. pending the arrival of emerg

ren’s Jhospital. ‘Phe Clinical Summary

Upon their ariival Jimny was tiausferced to the

foted:

"13 year old foundsubmerged in water at Sth Melb beach.

Pulled fom water approximately 1710h, unknown downtime, CPR commenced by bystanders.

Attended by emergency services, was in asystole, brief period of VF/VT, then back to asystole, MAS protocol continued, Arrived at RCH with CPR in progress, ETT in situ, ventilated. Rhythm of asytole, fxed dilated pupils. CPR continued. Venous gas obtained, pH 6.36. Decision to cease CPR, Patient declared deceased 1816h."

7, An Autopsy was performed by Dr Paul Bedford, Specialist Pathologist at Victorian Institute of Forensic Medicine, (VIFM). He formulated the cause of death and commented as follows:

"The fndings are consistent with the history of having died whilst in the water at the beach at Middle Park. No abnormalities were detected at post mortem and no drugs or common drugs or poisons.

In cases such as this (death at a young age) it is also worth considering abnormalities of the conduction system of the heart that may be caused by inherited (genetic) defects. Therepre it may be worthwhile having any siblings undergo a heart assessment by a suitably qualified cardiologist.

Material has been retained forfurther genetic studies if required.

No suspicious circumstances have been identified."

8 In the course of the CPU review a statement was obtained from Ms Porter, the Captain of the South Melbourne Life Saving Club. According to Ms Porter, South Melbourne Beach is a beach which has sandbars and gutters which form in certain climatic conditions. The gutters can be quite deep with active rips running through them; this can prove dangerous for the unwary and non-swimmers, On 29 December 2009, a southerly wind was blowing causing choppy conditions, with waves in the vicinity of forty-five to seventy-five centimetres in height, This was sufficient to produce deep gutters with active

rips forming on the beach.

9. Ms Porter advised that the incident occurred after hours; however there were staff members at the clubhouse at the time, who assisted with attempted resuscitation. The beach is usually patrolled on week-ends, public holidays and school holidays during the swimming season, It is a volunteer organisation only with limited resources available to patrol at all times. Ms Porter confirmed that apart from when lifeguards are on duty, whereupon they display their own signs, there is no signage indicating potentially dangerous rips and currents in the area, +

Life Saving Victoria (LSV) and Beachsafe

10. The Australian Beach Safety & Management Program (ABSAMP) database provides scicatific

and risk advisory formation regarding every beach in Australia, Phe database can be accessed theough

“ The Council representative confirmed that temporary corflute warning signs were evected soon alier this incident.

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the Surf Life Savings Beachsafe website.> It describes South Melbourne Beach with a general beach hazard rating of three out of ten. The website further advises that;

"The beach faces the south-south-west, and can receive moderate waves during strong southerly winds. When these occur, they maintain a 100 m wide beach fronted by a 50 m wide bar that is usually attached to the beach, with occasional rip channels, The rips are only active when waves are breaking over the bar,"

Port Phillip Council

11. Duting enquiries with Mr David Hehir, Foreshore Co-ordinator at Port Phillip Council, the CPU was advised that the Council was consulting with LSV and the Emergency Services Telecommunication Authority (ESTA) regarding signage and emergency markers. The Council installed temporary corflute signs following this drowning. It was anticipated that permanent signage will be rolled out by the end of 2011, with Sandridge Beach® as a priority followed by Port Melbourne Beach, South Melbourne Beach and the other beach areas to follow. The Council has also undertaken through LSV, programs to improve water safety skills for people from culturally and linguistically diverse (CALD) communities with the City of Port Phillip, Mr Hehir confirmed that;

"1363 children, youth and adults were involved in the program through 21 separate activities including beach programs, education sessions and training sessions.

The beach pwgrams were run at Sandridge and Port Melbourne Lié Saving Clubs and allowed partidpants to use surf skis, boogie boards, nipper boards, lif-jackets, rescue tubes and partake in beach running/equipment relays.

Education sessions incorporated Meet-a-Lifeguard sessions and Resuscitate a Mate sessions.

These interactive sessions gave CALD people a chance to learn about a lifeguards role and to develop firstaid skills.

Surf Bronze accreditation training was provided to six individuals, two of whom have gone on to joinPort Melbourne Life Saving Club as qualified patrolling members."

12, It is apparent that young Jimmy Ngyuen was an inexperienced swimmer who attended the beach with friends and unfortunately died from an unwitnessed and silent drowning in challenging conditions.

3 Auip:/Awww,sis.co between one and ten, with one being relatively safe fo ten being extr

Hfind-a-beachivic The website describes Victorian beaches with a hazard rating ly hazardous.

8 Brom informal dis ons with Alison Porter, Chit ptain of the South Melbourne Lite 8: rub the OPO was i SEVIOUS Pips Tarmniny SOF the Tiree 1 een ty. The beach is noonlar with familics as it is the ft oeach after

vest af the city.

4005

RECOMMENDATIONS: Pursuant to Section 72(2) of the Coroners Act 2008, I make the following recommendation connected with the death: :

Appropriate signage at all beaches in the Port Phillip municipality is an important initiative given their popularity and proximity to the Melbourne CBD: ,

1. The Port Phillip Council should consider installing permanent warning signs particularly in the area of South Melbourne Beach and any similar beach in the municipality which may pose risks to swimmers from troughs and rips.

Signature:

CONS A, “>

HEATHER SPOONER CORONER 19 January 2012

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