Finding into death of Jil Jayeshbhai Khokhara

IN THE CORONERS COURT COR 2024 001564 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner David Ryan Deceased: Jil Jayeshbhai Khokhara Date of birth: 24 February 1998 Date of death: 17 March 2024 Cause of death: 1(a) Drowning Place of death: Marengo Main Beach Marengo Victoria Keywords: Drowning – ocean beach – water safety

INTRODUCTION

1. On 17 March 2024, Jil Jayeshbhai Khokhara was 26 years old when he passed away at Marengo Beach in Victoria. At the time of his death, Jil lived in Tarneit with a number of housemates. He is survived by his parents and sister.

BACKGROUND

2. Jil was born in India and was raised by his family in the town of Surendranager.

3. In September 2023, Jil moved to Australia to pursue postgraduate study at La Trobe University. He resided in Tarneit with his best friend Rasik Malvaniya, Rasik’s wife, Sherya Malvaniya, and their cousin Meet Agola.

4. Jil did not have any relevant medical history.

THE CORONIAL INVESTIGATION

5. Jil’s death was reported to the coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (the Act). Reportable deaths include deaths that are unexpected, unnatural or violent or result from accident or injury.

6. The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death, and surrounding circumstances. Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death. The purpose of a coronial investigation is to establish the facts, not to cast blame or determine criminal or civil liability.

7. Under the Act, coroners also have the important functions of helping to prevent deaths and promoting public health and safety and the administration of justice through the making of comments or recommendations in appropriate cases about any matter connected to the death under investigation.

8. Victoria Police assigned an officer to be the Coronial Investigator for the investigation of Jil’s death. The Coronial Investigator conducted inquiries on my behalf, including taking statements from witnesses – such as family, the forensic pathologist, treating clinicians and investigating officers – and submitted a coronial brief of evidence.

9. This finding draws on the totality of the coronial investigation into Jil’s death including evidence contained in the coronial brief. While I have reviewed all the material, I will only refer to that which is directly relevant to my findings or necessary for narrative clarity. In the coronial jurisdiction, facts must be established on the balance of probabilities.1

MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Circumstances in which the death occurred

10. On 16 March 2024, Jil, Rasik, Shreya, Meet and their friend Jignesh Pelwala drove to the Otway National Park and camped overnight at the Beauchamp Falls campground.

11. On 17 March 2024 at around 12.30pm, after spending the morning exploring the Otways, Jil and his friends stopped at Marengo Beach on their way home.

12. Marengo Beach is situated southwest of Apollo Bay. It is not patrolled by Life Saving Victoria (LSV). The Beachsafe website managed by Surf Life Saving Australia classifies the beach as extremely hazardous and signage has been placed at the entry point from the car park to alert swimmers to various risks, including from strong currents and large breaking waves.

13. Jil and his friends situated themselves on the beach about 20 metres north of the steps leading down to the sand from the car park. At around 1.00pm, Jil, Rasik, Meet and Jignesh went for a swim in the ocean. Rasik was the only one of the group able to swim, so the others remained closer to the shore while Rasik swum further out.

14. After returning to the beach from his swim, Rasik noted that his friends had been pulled by the current away from the shore and they were observed to struggle in the surf. Meet had been closest to the shore and Rasik tried to assist him but the strong current pulled him away from Rasik’s grasp. At around this time, Shreya, who had been watching the events unfold from where she was sitting on the beach, contacted emergency services.

1 Subject to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336. The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals unless the evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments.

15. Breanna Hurst was sitting on the beach at this time and she bravely entered the surf and pulled Meet from the water. He was not responsive. Rasik assisted Breanna to pull Meet onto the beach whereupon he commenced cardiopulmonary resuscitation (CPR), assisted by other members of the public. Meet was able to be revived shortly afterwards.

16. Breanna returned to the surf and rescued Jignesh and brought him to the shore. He was unresponsive. Other members of the public, including Rebecca Norman, Jordan Carreras, Valerie Johnson and Robyn Baines, assisted Jignesh onto the beach and provided first aid, including CPR.

17. Breanna again returned to the surf and rescued Jil and brought him to the shore. Jil was unresponsive and CPR was commenced by the members of the public on the shore, assisted by Rasik.

18. At around 1.26pm, Ambulance Victoria and Victoria Police arrived on the scene and took over the emergency response. Jignesh was transported by air ambulance to the Alfred Hospital in a critical condition. Despite the best efforts of all first responders, Jil could not be revived and passed away at the scene. He was pronounced deceased by paramedics at 2.09pm.

19. I commend the courage and focus of Breanna and the other first responders who provided critical assistance as the emergency unfolded. The community is well-served by such altruistic behaviour.

Identity of the deceased

20. On 17 March 2024, Jil Jayeshbhai Khokhara, born 24 February 1998, was visually identified by his friend and housemate, Rasik Malvaniya.

21. Identity is not in dispute and requires no further investigation.

Medical cause of death

22. Forensic Pathologist Dr Joanne Ho from the Victorian Institute of Forensic Medicine conducted an examination on 18 March 2024 and provided a written report of her findings dated 21 March 2024.

23. Toxicological analysis of post-mortem samples did not identify the presence of any alcohol or any commons drugs or poisons.

24. Dr Ho provided an opinion that the medical cause of death was 1 (a) Consistent with drowning.

25. I accept Dr Ho’s opinion. Further, given the circumstances of Jil’s death, I am satisfied that he in fact drowned.

FINDINGS AND CONCLUSION

26. Jil’s death was a tragedy which has devastated his family and friends. His death highlights the risks to swimmers at Victoria’s ocean beaches. Swimmers need to carefully and consciously assess their ability to manage the variable conditions at surf beaches before deciding to enter the water. Those who are not confident and sufficiently competent in the water to manage the potential hazards should approach Victoria’s ocean beaches with caution and swim at patrolled beaches. The communication of this message is particularly important as we head towards another summer where residents and visitors to Victoria will be visiting its beaches and waterways to enjoy the recreational activities they have to offer.

27. Pursuant to section 67(1) of the Act, I make the following findings: a) the identity of the deceased was Jil Jayeshbhai Khokhara, born 24 February 1998; b) the death occurred on 17 March 2024 at Marengo Main Beach, Marengo, Victoria, from drowning; and c) the death occurred in the circumstances described above.

COMMENTS Pursuant to section 67(3) of the Act, I make the following comments connected with the death.

28. Jil was the 27th person to drown in Victoria over the 23/24 summer season. Since 1 July 2023, 12 people born outside of Australia drowned in Victoria.

29. In its Aquatic Injury Prevention Agenda 2024-25, Life Saving Victoria (LSV) identified the following relevant water safety issues associated with high-risk populations, including multicultural communities: a) Lack of understanding or preparedness for open waterway conditions and dangers, particularly rip currents or strong currents; b) Lack of swimming ability;

c) People swimming outside the red and yellow flags at patrolled beaches, or swimming at unpatrolled beaches; d) Not reading aquatic safety signs and supervising others while not having adequate water safety skills or knowledge themselves; and e) Lack of water safety messages and programs which are accessible and appropriately tailored for CALD2 communities.

30. Evidence shows that for new arrivals to Australia, water safety is rarely considered as a priority and there is a lack of understanding of swimming safety. This includes a poor understanding, or misinterpretation, of the meaning of the red and yellow beach safety flags, and limited knowledge and awareness of general safety around where to swim and how to recognise dangers. Surf Life Saving Australia (SLSA) has attempted to address this in part with the development of the Beachsafe site: https://beachsafe.org.au/ – this is freely available in over 100 languages and provides safety information on all beaches within Australia, including when they are patrolled and potential safety considerations at each location.

Additionally, the Beachsafe website provides a range of other safety tips and information, including beach safety information videos in a number of different languages that were developed for populations or groups determined to be at a high risk of drowning (https://beachsafe.org.au/surf-safety/multilingual).

31. The Royal Life Saving Society- Australia, LSV and SLSA are well aware of the ongoing water safety risks to multicultural communities. They have conducted significant research and produced a series of publicly available communication materials for multicultural communities explaining the dangers of multiple aquatic environments and risk factors. These have been translated into a number of languages.3 They also deliver a number of practical and theoretical education programs to a wide variety of groups, including newly arrived refugees, asylum seekers, migrants and international students.

2 Culturally and linguistically diverse.

3 https://www.royallifesaving.com.au/stay-safe-active/communities/multicultural-communities/resources-by-language.

32. In 2024, RLSSA submitted a formal proposal to the Department of Home Affairs advocating for the inclusion of water safety information in visa processing and arrival documentation for refugee entrants to Australia, as well as adjustments to policy to ensure new migrants had access to existing swimming and water safety education programs that are currently only available to residents.

33. The Australian Water Safety Council has also developed the Australian Water Safety Strategy 2030 in furtherance of its commitment to improving water safety in Australia, which includes a focus on multicultural communities.

34. Further, LSV’s Aquatic Injury Prevention Agenda 2024-25 contained the following recommendations relevant to multicultural communities: a) Explore recruitment strategies to involve overseas-born peoples in education sectors to optimise water safety messaging for CALD communities; b) Encourage and empower people who are born overseas to educate their families, friends and communities about water safety; c) Target safety messaging in areas with high visitation and drowning fatalities among cultural groups and international visitors, using languages relevant to these demographics; d) Expand the delivery of tailored messaging based on age country of origin and language preferences of visitor groups er. Through billboards, printed materials, social media and other channels; e) Investigate optimal timing for delivery of aquatic safety messages to various tourist groups; and f) Evaluate the effectiveness of tailored prevention strategies for different types of international visitors, such as water safety education programs offered by Australian universities for international students and perceptions of beach safety signage for optimal implementation.

35. I endorse the recommendations made by LSV and other water safety bodies which are targeted towards preventing drowning deaths, including with a focus on multicultural communities.

I convey my sincere condolences to Jil’s family for their loss.

Pursuant to section 73(1A) of the Act, I order that this finding be published on the Coroners Court of Victoria website in accordance with the rules.

Pursuant to section 49(2) of the Act, I direct the Registrar of Births, Deaths and Marriages to amend the cause of death to the following “1(a) Drowning”.

I direct that a copy of this finding be provided to the following: Jayesh Khokhama, Senior Next of Kin Life Saving Victoria Sergeant Robert Ashton, Coroner’s Investigator Signature: ___________________________________ Coroner David Ryan Date : 01 October 2024 NOTE: Under section 83 of the Coroners Act 2008 ('the Act'), a person with sufficient interest in an investigation may appeal to the Trial Division of the Supreme Court against the findings of a coroner in respect of a death after an investigation. An appeal must be made within 6 months after the day on which the determination is made, unless the Supreme Court grants leave to appeal out of time under section 86 of the Act.