Finding into death of Keith Flower

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2012 0706

FINDING INTO DEATH WITHOUT INQUEST

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

I, JOHN OLLE, Coroner having investigated the death of KEITH FLOWER

without holding an inquest:

find that the identity of the deceased was KEITH FLOWER born on 3 December 1984

and the death occurred on 21 February 2012

at Yarra River, East of Princes Bridge, Melbourne 3000

from: l(a) DROWNING

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

1. Keith Flower was aged 27 years at the time of his death.

2. The coronial brief has fully addressed the tragic circumstances of death.!

3. Keith arrived in Australia on 24 August 2010. He worked as a restaurant manager and

lived with friends in St Kilda.

Circumstances

4, On the evening of Tuesday, 21 August 2012 Keith was drinking with friends at the Riverland Bar, located on the northern bank of the Yarra River. He consumed approximately two pints, and two half pints of full strength beer over a period of

approximately four hours.

Be Keith stated to friends he was bored and would swim across the Yarra River. Despite

attempts to dissuade him, Keith removed most of his clothing and entered the Yarra River

A copy of the coronial brief will remain on the court file

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from a stairwell located east of the Riverland Bar. He was wearing underwear, denim

jeans, a leather belt and socks. A friend joined him.

They swam approximately half way across the river before witnesses observed Keith begin to struggle and panic. Keith called for assistance from his friend, who saw Keith being dragged by the river current. Keith swallowed a mouth full of water and submerged before his friend dived under water in an attempt to boost him up. Keith continued to struggle and panic and, whilst kicking his legs, made contact with his friend, forcing him to release his hold. His friend resurfaced for air, then made repeated attempts to locate Keith by diving

under the water, Keith was unable to be found.

A bartender from Riverland Bar, and two friends of Keith’s friends, swam to the vicinity of

Keith’s disappearance, and searched for a number of minutes before retiring to the bank.

Emergency services attended and subsequently located Keith on the river bed, below his last sighting. The depth of the river is approximately 3.1 metres at that point. At the time of the incident the river current was described as strong and the water temperature cold.

Visibility under water was zero.

Post mortem medical examination

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On 22 February 2012, Dr Linda Iles, Forensic Pathologist at the Victorian Institute of

Forensic Medicine, performed an external examination on the body of Keith Flower.

Dr Iles found the cause of death to be drowning.

The circumstances of Keith’s death are tragic. Keith’s family have suffered a devastating loss. My investigation cannot salve their loss or diminish their pain. However, the circumstances in which Keith died, are not unique. Too many, predominantly, young men,

have lost their lives in similar circumstances. I address prevention issues shortly.

I offer the family and friends of Keith, my sincere condolences.

Coroners Prevention Unit

Keith Flower and Son Man Song died in similarly tragic circumstances. At my request, the Coroners Prevention Unit (CPU) undertook a review in the hope of identifying prevention

lessons.

? The Coroners Prevention Unit is a specialist service for coroners created to strengthen their prevention role and provide them with professional assistance on issues pertaining to public heath and safety.

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14. The CPU reviewed Victorian drowning deaths between January 2000 and June 2013 to

identify any similar deaths. The inclusion criteria were:

— The drowning death was reported to the Coroners Court of Victoria between January 2000 and June 2013.

— The circumstances of the death were consistent with unintentional drowning.

= The drowning death occurred in the Yarra River in the City of Melbourne Local Government Area (LGA), including the stretch of the Yarra between Punt Road Bridge and the West Gate Bridge (the stretch of the Yarra in which both Son Man Song and Keith Flower drowned)

15. The CPU identified 14 drowning deaths where the body was found within the Yarra River and met the inclusion criteria. Eleven deceased were found to have a detectable blood

alcohol level post-mortem; the detected levels raged from 0.06g/100mL to 0.3g/100mL.

A significant finding

16. That, 14 drowning deaths occurred between January 2000 and June 2013 in the relatively small inland body of water between the Punt Road Bridge and West Gate Bridge, is significant. To put this finding in context, a 14 March 2013 Herald Sun article reporting on Victoria’s “worst” beach areas for drowning deaths between July 2000 and June 2012, found that Warrnambool was the location with the highest frequency (eight), followed by Frankston (with six), Lorne and Seaford (with five each).

7: The CPU identified the Finding of Coroner Kim Parkinson following her investigation into the death of Daryl Rolton (2009/1473). Mr Rolton drowned after entering the water at a popular swimming spot along the Wodonga Creek, having drunk a significant amount of alcohol. Pursuant to s 72(2) of the Coroners Act 2008, Coroner Kim Parkinson made the

following recommendations:

“I recommend that the State and Local Government provide funding to life saving organisations, to enable them to continue to promote public safety messages as to the danger of alcohol related drowning, specifically in country

and regional areas.

I direct that a copy of this finding be provided to the Minister for Local Government Victoria, the Municipal Association of Victoria and Life Saving

Victoria, and to the New South Wales Coroner at Albury.”

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Life Saving Victoria (LSV) response

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In its response to Coroner Parkinson’s recommendations, LSV described its role in the

Victorian community as follows:

“Life Saving Victoria's mission is to prevent aquatic related death and injury in all Victorian communities and has the vision that all Victorians will learn water safety, swimming and resuscitation, and be provided with safe aquatic environments and

venues.” LSV indicated that it accepted Coroner Parkinson’s first recommendation, and noted that:

“[...] alcohol remains a significant contributing factor in drowning deaths with an average of 19% of drowning incidents attributable to alcohol use in Victoria over 2000-2010. A recent NSW study also found that for the 18 to 34 age group, close to

1 in 2 male drowning deaths were linked to alcohol.”

LSV noted that it has been involved in a range of drowning prevention programs including the Don’t Drink and Drown public awareness campaign, and the Open Water Learning

Experience (OWLE) regional education initiative. However LSV further noted that:

“Life Saving Victoria has proposed several steps for the future to prevent alcohol related drowning, including within country and regional Victoria. However, these

projects can only go ahead if funding is available.”

The CPU notes that on 27 February 2012, it had further contact with LSV regarding alcohol affected males drowning in inland waterways, following the death of Man Song Son. On 11 May 2012, LSV responded to the CPU and noted that since its to the coronial

recommendations in the Daryl Rolton case:

“[...] LSV has successfully developed partnerships in Government such as with the ‘Victorian Commission for Gambling and Liquor Regulation [...]. This partnership would assist the distribution of information and resources on behalf of LSV to promote Don’t Drink and Drown message throughout the community. For example this would provide opportunities through the website, quarterly newsletter The Grapevine, direct to liquor accords, as well as linkages for expansion of the program

through the various stakeholder networks.”

LSV further indicated it believes targeted programs are required to reach those most at risk

of alcohol related drowning in inland waterways.

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Department of Justice (DOJ) response

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On 23 July 2010 the Department of Justice responded to the recommendations made in the death of Mr Daryl Rolton (2009-001473), stating that:

“Since 2003 the Victorian Government has provided $12.1 million to Life Saving Victoria (LSV) through the DOJ Water Safety Program. This program incorporates deliver of the Play it Safe by the Water campaign, which address the need for safe and responsible behaviour while enjoying Victoria’s pools, beaches, rivers and lakes

by increasing community awareness of safety issues.

DOJ, along with LSV were continually monitoring all drowning related deaths in Victoria and responses responds to any emerging trends with specific targeted campaigns and programs. The three messages of the campaign are NEVER turn your back, NEVER swim alone, and LOOK before your leap, and the primary target

audience are parents and carers of toddlers and the young male risk taker.”

DOJ noted this strategy had been employed over the 2009-10 summer targeting the young male risk taker audience. Along with Surfing Victoria, LSV used role models to promote key water safety messages such as Don't Drink and Drown to this audience. DOJ stated that they will continue to work with LSV to promote water safety messages to its key

audiences through the Play it Safe by the Water campaign.

Policy context

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In addition to the LSV and DOJ information on water safety policies and strategies provided to the CPU in response to Coroner Parkinson’s recommendations in the death of Daryl Rolton, the CPU identified the Australian Water Safety Strategy 2012-2015 (AWSS), which was launched in June, 2012 with the aim of reducing the level of drowning fatalities per year by 50% by the year 2020. The AWSS was developed by the Australian Water Safety Council (AWSC) in collaboration with water safety agencies, government

and other groups.

My referral to CPU following my investigations into the deaths of Keith Flower and Son

Man Song focussed on the following points:

• Keith Flower and Son Man Song were both young males who drowned after intentionally entering the Yarra River in the vicinity of the Princes Bridge, while

under the influence of alcohol. Neither male intended to drown.

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The CPU could find only one previous Victorian coroner’s finding that addressed the dangers of alcohol-related drowning. This finding was directed to LSV and the DOJ.

In their responses to the recommendation, both LSV and the DOJ indicated their acceptance that alcohol remains a significant contributing factor in Victorian drowning deaths, and outlined various strategies being pursued to reduce these

deaths. The strategies were predicated on propagation of water safety messages.

At a national level, alcohol involvement in drowning is also acknowledged as a

significant issue in the Australian Water Safety Strategy.

The CPU identified 14 possible unintentional drowning deaths that occurred in the Yarra River between the Punt Road Bridge and West Gate Bridge (the section of the Yarra River that falls within the City of Melbourne). In 11 of these 14 deaths, the deceased had a detectable blood alcohol level post-mortem.

However, the lack of information regarding the circumstances of most of these deaths, has frustrated attempts to draw conclusions as to their relevance to the

deaths of Son Man Song and Keith Flower

RECOMMENDATIONS

Pursuant to section 72(2) of the Coroners Act 2008, I make the following recommendation(s)

connected with the death:

My recommendations are designed to encourage the relevant organisations responsible for drowining prevention to consider what further could be done in the City of Melbourne to

reduce unintentional Yarra River drownings.

Recommendation 1

I recommend that Life Saving Victoria convene a meeting with the City Melbourne and Victoria Police to identify targeted drowning prevention interventions to prevent or deter alcohol-affected persons from entering the Yarra River within the City of Melbourne, particularly around Crown Casino and the Docklands, where there appears to be a

disproportionately high frequency of drownings.

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2. In light of the interest of the Australian Water Safety Council in preventing alcohol related drownings, and its interest in developing evidence based strategies to achieve this, I make

the further recommendation: Recommendation 2

That the Australian Water Safety Council consider whether the stretch of the Yarra River between the Punt Road Bridge and West Gate Bridge is an appropriate location to trial any interventions aimed at reducing alcohol-related unintentional drowning, given that there

appears to be a disproportionately high frequency of drownings in this area.

Finding

I formally find that the cause of death of Keith Flower is drowning.

I direct that a copy of this finding be distributed to the following: The family of Keith Flower Investigating Member, First Constable Brendan Clark, Victoria Police

I direct that a copy of this finding be distributed to the following agencies for their consideration: City of Melbourne Victoria Police Life Saving Victoria Department of Justice Australia Water Safety Council

Signature:

JOHN OLLE CORON Date: 23 ary 2014

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