Coroner urges proper supervision of children in water

Tuesday 12 November 2024

In a finding released today, Victorian Coroner Sarah Gebert observed that inadequate supervision played a role in the drowning deaths of 43 children aged four and under in Victoria between 1 January 2010 and 31 March 2024. The finding has prompted Her Honour to emphasise the need for parents and carers to exercise vigilance when supervising children in and around water.

The finding comes after a coronial investigation into the death of a two-year-old boy, Master K, at Crown Towers hotel in November 2021.

On 19 November 2021, Master K, his two siblings and two young cousins attended the Crown Towers pool area under the supervision of Ms L – Master K’s mother. The children played in the pool while Ms L took photos and videos on her phone. The pool area is divided into a large open pool with an adjoining shallow toddler pool section separated by four square landings of 1.5 to 2 metres wide and steps leading down to the adult pool. The pool area is not staffed by a lifeguard.

Shortly before the pool closed for the evening, Ms L answered a phone call and then remained looking down at her phone for several minutes whilst seated in the toddler pool. During this time, she did not notice Master K moving from the toddler pool and falling into the adult pool where he drowned.

CCTV showed that by the time another pool patron noticed Master K unresponsive in the water, he had been floating face down in the adult pool for over nine minutes.

Master K was transferred to the Royal Children’s Hospital. Over the next few days, there was no change in his condition and Master K passed away in hospital on 27 November 2021.

“Master K’s tragic death and the circumstances of his drowning highlight the need for close supervision of young children, especially in and around pools,” said Her Honour.

As part of the investigation, Coroner Gebert sought to understand the extent to which a lack of supervision contributed to drowning deaths of children in Victoria. The data showed that between 1 January 2010 and 31 March 2024, there were 47 drowning deaths of children aged between newborn and four years of age in Victoria. In 43 of these deaths, inadequate supervision was a factor.

Of the 47 deaths identified during the investigation, children aged one year represented the highest age group of drownings, with 16 deaths. This was followed by those aged two years with 11 deaths. Her Honour said that the vulnerability of these age groups was, in part, because children aged 1 to 2 become more mobile, and are curious and unpredictable.

Her Honour noted that in 11 of the 47 cases, coroners had previously made comments relating to the specific dangers faced by young children in the context of water safety. Themes included:

bodies of water are a temptation to young children because they represent a fun activity and adventure, however, children do not adequately understand the dangers of water
parents therefore need to be vigilant and exercise adequate supervision of children in and around bodies of water and a brief lapse of vigilance can have tragic consequences
children can drown in as little as 20 seconds, in shallow water (only a few centimetres deep) without making any noise
use of life vests or other buoyancy aids are not a substitute for close, focused, and active supervision
adults should not assume someone else is supervising the child.

In her comments, Coroner Gebert reiterated safety messages consistently repeated by child safety and water related authorities including the Royal Children’s Hospital, Kidsafe Victoria and Life Saving Victoria:

supervision means constant visual contact, not the occasional glance
adults should actively supervise children, even if the child can swim
supervising adults should avoid all distractions, including using a phone or answering the door
do not leave older children (under the age of 16 years) to supervise younger siblings
children under five years must be within arms’ reach, and children under 10 years must be clearly and constantly visible and directly accessible.

Coroner Gebert directed the finding be provided to the Royal Children's Hospital, Ambulance Victoria, the Commission for Children and Young People, Kidsafe Victoria and Life Saving Victoria.

A copy of the finding can be found here: Finding into the death of Master K

Media contact:
Claudia Hodgens
P: 0407 403 371
E: mediaenquiries@coronerscourt.vic.gov.au