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As part of her investigation, the coroner said she had sought to understand if a lack of supervision contributed to drowning deaths of children in Victoria.
She found that from January 1, 2010, to March 31, 2024, 47 children aged four and under drowned in Victoria. Of the 47, inadequate supervision was a factor in 43 drownings.
Children aged one represented the highest age group of drownings, with 16 deaths, followed by two-year-olds, with 11 deaths.
Gebert said the vulnerability of these age groups was, in part, because children aged one to two become more mobile, and were curious and unpredictable.
Safety messages consistently repeated by 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) to supervise younger siblings.
- Children under five years must be within arms’ reach, and children under 10 must be clearly and constantly visible and directly accessible.
The findings also follow the death of two-year-old Lara boy Luka, who drowned in a dam near his home in June after he had wandered off from his mother.
In May, a court convicted the Victorian Education Department and fined it $100,000 for breaching workplace safety laws over the death of year 2 student Cooper Onyett, aged eight, who drowned at a Port Fairy swimming pool on the last day of his school camp two years earlier.
Earlier inquests, Gebert found, had also raised issues, including that bodies of water were a temptation to young children because they represented a fun activity and adventure, but children did not adequately understand the dangers of water.
The use of life vests or other buoyancy aids were not a substitute for close, focused and active supervision, she noted, and adults should not assume someone else is supervising the child.
“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,” the coroner said. “Children can drown in as little as 20 seconds, in shallow water (only a few centimetres deep) without making any noise.”