Finding into death of Bobdeb Nkondogoro

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2008 / 1019

FINDING INTO DEATH WITH INQUEST

Form 37 Rule 60(1) Section 67 of the Coroners Act 2008

Inquest into the Death of: BOBDEB NIKONDOGORO

Delivered On: 3 March 2015

Delivered At: Coroners Court of Victoria

65 Kavanagh Street

SOUTHBANK Vic 3006 Hearing Dates: 3° to 5 November 2010 Findings of: PETER WHITE, CORONER

Police Coronial Support Unit Sergeant J Brumby

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I, PETER WHITE, Coroner having investigated the death of BOBDEB NKONDOGORO !

AND having held an inquest in relation to this death on 3 and 5™ November 2010 at Coroners Court MELBOURNE

find that the identity of the deceased was BOBDEB NKONDOGORO

born on 15 May 1995

and the death occurred on 9 March 2008, at Dandenong Creek, Dandenong 3175

from:

1(a) DROWNING?

in the following circumstances:

Janvier Lkondogoro

Bobdeb and his cousin Janvier Nkondogoro, (Janvier), were near neighbours, residing in

Dandenong near Melbourne.

In his witness statement, Janvier stated that he and Bobdeb decided to go swimming in a creek neat Bobdeb’s house. They didn’t tell anyone that they were going swimming and both boys

road their bikes to the creek.

Janvier stated that:

‘When we got there Bobdeb went into the water. I don’t know how long he was in the water for before I couldn’t see him. I got a stick and used that (in the water) to try to

find him, but I couldn’t.’

Later Janvier alerted a little boy who informed a woman. He could not remember what

occurred thereafter.’

In his testimony to the court, provided on 4 November 2010, Janvier aged 14 years at the time of the incident, gave a different account stating that he had not accompanied Bobdeb to the

creek and first became aware of the matter only after Bobdeb had got into difficulty.

' This inquest was conducted in tandetn with my inquest into the death of JOHN KABIRO NDIRANGU NKONDOGORO, see Coroners Case 0715 of 2009. The comments and recommendation included below from page 5 were made in respect of both deaths.

? See exhibit 9 page 25.

3 See exhibit 7 page I.

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He was riding his bike but without any plan to go to the creek and that he rode to the creek from a distance, only after he was informed by another Sudanese youth, a nine year old, that

Bobdeb was there, and in difficulty.

Janvier did not know the name of this other boy, or how he might be contacted.

Later in testimony Janvier became conflicted about his recollection as to which of the above version of events was true and in the circumstances I direct myself to attach little weight to his evidence concerning how Bobdeb came to be in the Dandenong creek, or once there, how he

came to get into difficulty.

Javier further stated that he was Sudanese, and arrived in Australia in 2005. He could not

swim and that he had not learnt to swim since his arrival. He did not know if Bobdeb could

swim or not swim.

Beatrice Siyajali

12,

Bobdeb was the eldest of five children of Beatrice Siyajali who moved to Australia from Tanzania in March 2007. A sixth child was born after her arrival. Bobdeb played frequently with his older cousin Janvier, and this often involved the riding of their bikes.® On the day of his death, Bobdeb left the house without mentioning swimming. The next time she saw him

was on the creek bank, where she was called upon by police to make an identification.

He had never previously mentioned swimmiing to his mother.

Tanzania is a war torm country and there was no time for her children to learn how to swim.

Bobdeb was described by his mother as a happy, fit and healthy boy.

Sergeant JS Blackburn

At 6.58 pm on Sunday 9 March 2008, Sergeant Blackburn was informed over police radio, of a missing 12-year-old boy. Sergeant Blackburn was told that about 10 minutes earlier, the boy had been seen in trouble in the Dandenong creek. At approximately 7.08 pm he parked his car next to a locked gate, which gives access to a dirt track, which runs parallel to the creek. He received further information from a Senior Constable Griffiths who had located a number of

witnesses. At that stage, three young boys approached on bicycles and then accompanied

• See transcript page 58.

5 Sce transcript page 61 and exhibit 7 page 1.

§ Janvier described his cousin as his best friend. See transcript page 58

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19,

21..

Sergeant Blackburn to the place where they had last seen Bobdeb, which was some 750

meters upstream in a northerly direction from the Kidd’s Road bridge.’

There he met Janvier who indicated the point where he had last seen Bobdeb, which was on the eastern side of the creek about 1.5 meters into the water from the embankment. The water in that area appeared to be murky with no visibility under the water. It was seen to be flowing slowly in a southerly direction towards a shallow section, some 10 meters from where Bobdeb

had last been seen.

Sergeant Blackburn then directed Senior Constable Griffiths to enter the water at the shallow rocky section and to work his way upstream in an attempt to locate Bobdeb. He was supported in this endeavour by Constable Savin, who used a long pole located nearby, to

attempt to ‘feel’ under the water.

Sergeant Blackburn then requested the Police Search and Rescue squad to attend. CFA units from Dandenong and Hallam and members from MAS and members of the Dandenong

Traffic Management Unit and Uniform Section also arrived.

Following consultation with Sergeant Velthuis (of the Police Search and Rescue Unit) who contacted Sergeant Blackburn at approximately 7.35 pm, the search being undertaken by Senior Constable Griffiths was abandoned, this because his lack of training was considered by

Sergeant Velthuis, as likely to constitute a danger to his own safety.

Thereafter the situation was explained to Bobdeb’s parents, who were present at the scene together with other members of the local African community, Bobdeb’s mother and stepfather

confirmed that their son had not returned home.

Later State Emergency Services (SES) arrived and illuminated the scene. SES did not further participate in the rescue, as it was by then presumed that the action to be taken was a recovery

action only.

At approximately 8.45 pm, the Search and Rescue Unit arrived. Soon after two divers entered the water and a shortly afterwards Bobdeb’s body was located and brought to the bank, this from the area of water in which he had last been seen. Bobdeb was deceased and his family

viewed his body.

” See statement at exhibit 13 page 5.

5 See exhibit 13 page 1.

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Senior Constable J Savin

On Sunday 9 March 2007, Senior Constable Savin was conducting mobile uniform duty with Senior Constable Griffiths. At around 6.55 pm both officers were notified that a 12-year-old boy was missing, and attended the scene with the assistance of two unnamed persons. Both

officers assisted the search in the manner set out above.

At approximately 9.30 pm, Bobdeb’s body was recovered by a police diver, who later advised

that the recovery had taken place at a depth of 2.6 meters, and from under a submerged log.

Comments

Pursuant to section 67(3) of the Coroners Act 2008, I make the following comment(s) connected with the deaths of both BOBDEB NKONDOGORO and JOHN NDIRANGU.

26,

27,

Both Bobdeb Nkondogoro and John Ndirangu were young Aftican immigrants who had recently arrived in Australia, and were non-swimmers in their own countries, respectively Tanzania and Kenya.” Additionally neither had learnt to swim or had any experience or

knowledge of swimming conditions in this country.

Tragically, over the last ten years to December 2014, a total of 17 similar accidental drowning deaths, have occurred in open waters in Victoria,- all in respect of recently arrived immigrants who had little or no swimming experience and no experience of our prevailing swimming

conditions, and associated peril.’°

Lattach at attachment A, a list of these cases, which includes the two matters, which have been

examined in this inquest.

From our consideration of all of these matters it is apparent that information-about swimming, and the dangers involved for non-swimmers in swimming in open waters, is made available to persons newly atrived in this country. In this regard, I note that a booklet published on behalf of the Commonwealth Department of Iminigration and Citizenship, to new immigrants

called ‘Beginning Life in Australia’, first published in’ January 2009, provided basic

° Bobdeb arrived in Australia with his family in March 2007, while John arrived only a few weeks before his death.

There is no evidence to suggest that either received information concerning swimming conditions in Australia, or advice concerning learning to swim, after their arrival.

10 This number excludes those cases, which involved deliberate self-harm together with those matters where the deceased was over the age of 25 years. Further all of the deceased persons in question drowned in a natural water environment, with drowning arising from fishing or boating incidents, together with drowning in swimming pools and baths, all excluded. This information was provided to the Court from research undertaken at my request by the Coroners Prevention Unit.

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28,

29,

31,

information from that time about swimming, but that this was achieved principally by

reference to the Swim Australia website,!!

I further note that this particular publication deals extensively with a large number of issues, relevant to adjustment to life in Australia.'? Language and cultural difficulties aside, it is clear

that there is an enormous amount of material for new arrivals, to take in.

Given the complexity of learning about such matters, I consider that the manner of the delivery of information about swimming in open water should be viewed as being at least as

important as the content of the material itself.

Of particular interest then in the context of helping prepare youngsters to take advantage of their new environment are those programmes, which are practically designed to offer

swimining lessons to new arrivals, especially to youthful new arrivals.

Following on from this perspective the Court has endeavoured to examine several previously developed ideas, concerning the actual delivery of learn to swim opportunities, which

approaches are currently or until recently were, in operation.

Lifesaving Victoria (LSV) has recognised the importance of this delivery aspect and has various projects underway, aimed at improving communication with people from Culturally

and Linguistically Diverse Communities, (CALD).”

LSV_ has previously obtained funding from the Federal Government Department of Immigration and Citizenship for the ‘Water Connections Project’. This project was aimed at CALD communities within the City of Hume, in the western suburbs of Melbourne, and offered important water safe information. The project enabled participants to learn about their local pools and provided them with aquatic industry traing. Over 6000 CALD community members have participated in this project and LSV is hoping to receive approval to continue

and extend this Federal Government supported initiative.

Further Vic Health funded the ‘Learning for Life’ project that provided some 70 children,

aged 4-15 years with the opportunity to learn how to swim in Hoppers Crossing, also part of

the western suburbs of Melbourne."4

"! See exhibit 11(d). There is no translation of the website.

2 At the time of inquest this publication was offered in a total of 38 languages. See exhibit 11(d), at page 2.

Additional assistance continues to be provided by the Federal Government Department of Immigration and Citizenship, through LSV. See paragraph 12 and also recommendation 1, below.

3 See footnote 18.

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35. The Department of Justice in the State of Victoria, also funded the ‘On the same wave’ project, which aimed to support lifesaving clubs with the resources and connections to CALD communities, to run culturally inclusive programmes. The project was adopted by Edithvale, Altona and Sandridge Life Saving Clubs and over 5000 CALD community have members participated. '*

36. Learn to Swim Victoria also offers a broad based approach to learning to swim, to the

community as a whole.

37. Additionally Spirit West Services, the community arm of the Western Bulldogs AFL football club, until recently, provided a number of water safety programmes in the western suburbs, '® The primary aim of the project was to increase water safety and awareness amongst refugees, and immigrants. In providing this service Spirit West worked in partnership with aquatic bodies including LSV, Learn to Swim Victoria, and Aquatics and Recreation Victoria,- this to deliver its programme, which included open water learning lessons at the beach, pool based

and ‘dry’ activity information sessions.

38. Life Saving Victoria’s most recent annual report details further work undertaken in Victoria, with Meibourne’s Aftican Community over the 2013 and 2014 12-month period. This group, while not necessarily all recent arrivals to Australia, evidently benefited from the programme and its focus on the needs of adults and young adults who have arrived in this country, without

having had the learn to swim opportunities of those who have been brought up here. 7

14 This project continued until 2011.

15 This project also continued until 2011.

'6 Spirit West Services no longer directly deliver swimming programmes to immigrants and refugees who have settled locally, but rather in partnership with the Hobson’s Bay Couneil, LSV and Aquatics Victoria,- support these groups with their own previously existing programmes.

17 See 2013-14 Report at page 9.

‘A breakthrough community project in 2013/14 saw over 1000 members of Melbourne’s African community engaged in water safety programs throughout the year. The multifaceted program, delivered across Melbourne’s West, South East and Inner City, included beach activity days delivered at lifesaving clubs, training courses in pool lifeguarding, opportunities to participate in learn-to-swim lessons and the “Kingston Beach Safety Day” involving a range of local emergency services, hosted by Carrum Surf Life Saving Club.

In addition to delivering valuable lifesaving and water safety skills to this target group, the project fostered new relationships between African participants and lifesaving clubs, aquatic facilities and emergency services. It also provided foundation-swimming skills for participants to move into lifesaving activities; provided skills for participants to gain employment in the aquatic industry; and developed aquatic role models and positive community stories.

Empowering Multicultural Lifeguards

With almost half of Victoria’s population comprising of people who were either born overseas themselves, or who have at Icast one parent who was born overseas, providing water safety for Culturally and Linguistically Diverse (CALD) communities is vital,

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39. It is self-evident that learning to swim cannot be achieved over night, and that instruction requires effort by properly qualified personnel, as well as the commitment of time and energy, and usually a financial contribution by participants and their families. It is also apparent from reports concerning the above programmes, that the there has been difficulty in securing on going commitment to learning to swim programmes from individual participants as well as their families and care providers. Additionally, there are both language and cultural differences, which can emerge and in some instances attendance commitment has waned because of existing commitments to (competing) school, family, sporting and work related,

demands."

40. Financial issues for participants have also made certain programmes difficult to sustain.

41. The most important lesson so far learnt appears to be that learn to swim programmes need to be targeted and specific to migrant / refugee communities. These communities often rely on

word of mouth and direct marketing.

42. As one witness commented, you can’t hope to have success with a, ‘we will build it they will come approach.’ Rather the building of networks and on going contact, with a community

member or members, is much more likely to lead to group commitment.

43. To be specific, having liaison with various new arrivals directed through existing community based settlement agencies, appears to have resulted in the greatest success, (reference both recruitment and ongoing participant commitment). Further such settlement agencies may also be expected to have experience in dealing with the several aquatic agencies operating in the

field.'°

44. It is also the case that while newly arrived parents may see advantages for their children in

learning to swim, parents themselves are much nore reluctant to participate.

With numerous barriers to participation in water safety and aquatics, the information gap for these communities is large.

A recent initiative between YMCA Victoria and Life Saving Victoria has opened the door for CALD graduates of LSV’s training programs to work as pool lifeguards and swimming teachers at a number of YMCA’s Melbourne aquatic and recreation centres. After completing their pool lifeguard training through LSV’s multicultural pathways program, eight graduates from within the African, Afghan and Burmese communities have been the first to take up this employment opportunity. Enabling these young people to undertake pool lifeguard and learn-to-swim teacher training is important not only for their own employment development, but for sharing vital water safety messages with CALD communities. As role models, these latest Aquatic industry employees can inspire others in their community.’

'8 Seemingly small issues like online registrations and paying by credit card, can create significant barriers for communities who are new to the country.

'9 Support agencies are both mainstream supporting all new arrivals, or ethno specific. The involvement of these agencies who endeavour to provide support to new artivals across all aspects of settlement in Victoria, is seen as a vital link between learning to swim and the aquatic agencies, which themselves are best placed to provide that instruction.

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45. Young adults have also often shown reluctance to commit, or once involved have sometimes withdrawn, perhaps not understanding the need for self-motivation, and a commitment to the practise needed to learn to swim. This of course is frustrating for programme providers and

wasteful of their always limited financial resources.

46, Finally, it is clear that Life Saving Victoria has emerged as a leader in the successful delivery of successful instruction in this area, through its multicultural beach prograinmes. These programmes directly confront the most difficult of swimming conditions while offering the additional benefit of creating a mechanism for recruitment of interested persons, into lifesaving clubs around the state. Beach swimming is also seen as attractive to new arrivals, and as a cheaper alternative, which is likely to create a more convivial atmosphere than the local swimming pool, for family outings and for spending time with new friends and

neighbours.

47. Success has also been seen, when schooling in swimming is tied to a larger objective, such as learning English at a language school, or perhaps even as a class option for new arrivals (in place of other physical exercise options), offered at both primary and secondary school levels.

The extension of these possibilities is also deserving of consideration.

RECOMMENDATION

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

t) That the Department of Sports and Recreation in the State of Victoria, in partnership with the Federal Government Department of Immigration and Citizenship, - seeks to examine how members of recently arrived immigrant communities to Victoria, might best be taught

how to swim safely in open water and continue to provide support for that objective.

I direct that a copy of this finding be provided to the following: The Family of Bobdeb Nkondogoro The Family of John Ndirangu

The Secretary of the Department of Immigration and Citizenship, in the Commonwealth of Australia

The Secretary of the Department for Sports and Recreation, in the State of Victoria

The Secretary of the Department of Justice and Regulation, in the State of Victoria, (paragraph 35 refers).

The Chief Executive of Lifesaving Victoria, Attention: Bernadette Mathews

The Chief Executive of the Western Bulldogs Football Club, Attention: Kiemi Lai,(paragraph 37 refers).

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The Chief Executive of the Australian Football League, (paragraph 37 refers).

The Manager, Coroners Court Prevention Unit, Attention: Jeremy Dwyer and Joe Vitale

Signature:

PETER WHITE

CORONER <a Date: 3 March 2015

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Attachment A

Drowning of young people recently arrived to Australia 01/01/2000 — 31/12/2014

LCN Country of Origin Location of Sex | Swimming/ Body of Death Sightseeing* | water 20044545 Pakistan Halls Gap F Sightseeing River 20050222 Ethiopia Maribymong | M Not known River 20064059 Afghanistan / Pakistan Wahring M Swimming River 20064686 Afghanistan Frankston F Swimming Sea 20075022 India Anglesea M Swimming Surf 20075023 India Anglesea F Swimming Surf 20081019 Africa Tanzania Dandenong M Swimming Creek 20081386 Pakistan Cape M Sightseeing Sea Woolamai 20081504 Pakistan Cowes M Sightseeing Sea 20083696 India Hawthorn M Sightseeing Creek 20090224 Asia (country not known) _| Edithvale M Swimming Sea 20090715 Africa Kenya Frankston M Swimming Sea 20104490 Africa Sudan Moe M Swimming Lake 20104545 Not Known Doncaster M Swimming Pool 20113016 South Korea Southbank M Swimming River 20140308 South Korea Blairgowrie M Swimming Sea 20146456 China Venus Bay M Swimming Surf

• Sightseeing refers to activities being conducted adjacent to natural water environments

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