Coroners Act 1995
Coroners Regulations 1996
Regulation 14
Form 4

I, Olivia McTaggart, Coroner, having investigated the death of

“a child”



The child died in the Royal Hobart Hospital in 2006 as a result of drowning in a dam.


At about 9.30am on  a Saturday in 2006, the child was at his home playing with his 6 year old friend. At about this time both boys walked up to a dam which is located at the rear of the property some 40-50 metres from the principal dwelling.

The dam which is relatively small in size is only some 15 metres in diameter and is about 3 metres in depth at the deepest point. It is surrounded by fencing, however the fence was in poor condition which allowed the boys easy access to the dam.

At the dam face the boys dragged an old vessel to the waters edge. The vessel in question was a small yellow tedder dingy mould which was some 1.7 metres in length. It was in a very poor condition, it was not watertight and it was not intended to be used as a flotation device

It appears that the boys then pushed the dinghy mould into the dam. The child climbed into the dinghy mould with his friend reluctantly also climbing in. It appears that at some point after entry into the water, the vessel became unstable and capsized throwing both boys into the water. His friend managed after some time to swim to the edge of the dam and got to the house to raise the alarm. However, the deceased could not swim and was unable to make it to shore.

The child’s  mother, went to the dam and found the deceased floating in the dam and pulled him to shore. The deceased’s grandmother who was also at the house assisted and rang the ambulance service. Shortly after this the deceased’s uncle, arrived at the property and responded to cries for help and immediately attempted CPR.

The ambulance unit arrived and commenced treating the child. Police also attended and assisted with CPR for about 20 minutes. The child was then transported to the Royal Hobart Hospital where he was unfortunately unable to be revived. 

A subsequent post mortem examination was carried out by the State Forensic Pathologist who ascertained the cause of the deceased’s death to be drowning.


Drowning has long been established as a significant risk factor to young children. 

According to the National Injury Surveillance Unit drowning is the second leading cause of unintentional injury deaths of 0-5 year old children in Australia.

A number of research findings have reported that drowning is the leading cause of death of children living on farms, and the most common location of these drownings is dams.

Statistics extracted from the National Coroners Information System[1] indicate that between July 2000 and July 2007, 32 children between the ages of 0-12 years drowned in dams or similar bodies of water on rural properties in Australia.

Research undertaken by the Victorian State Coroners Office and Department of Human Services published in 2002 titled “Unintentional Drownings: Toddlers in Dams in Victoria 1989-2001” identified five major factors contributing to young children drowning in dams.

The factors present in all cases studied were as follows:

1.  The child had reached a stage in their development where their gross motor skills enabled them to climb and wander some distance and their social skills had developed to a point where they were content to play on their own.

2.  The child was playing outside the house.

3.  There was a low level of carer supervision immediately before the incident.

4.  The dam was located in the vicinity of the house.

5.  There were insufficient barriers between the yard and the dam.

The research emphasised the particular dangers and drowning hazards to young children in rural environments.  For example: on rural properties carers and children tended to spend more time outside in the warmer months; carers were engaged in farm duties or home maintenance activities and therefore supervision was reduced; carers tended to believe that an inadequate fence around a dam provided adequate safety protection for children; generally there was also a lack of appreciation by carers that inland static waterways, such as dams, pose a significant risk to young children.

A number of recommendations for Victoria were formulated from the findings of this study.  They were as follows: 

  • future public awareness campaigns by water-safety organisations should be broadened to include safety messages that account for the differences between rural and urban water hazards, in particular the use of the “be dam careful” slogan should be reconsidered by the Victorian farming industry; 
  • any public awareness campaign should address carers consciousness of how quickly toddlers can get into danger, especially those most at risk in the one to three years age bracket; 
  •  the idea of creating “child safe areas” on properties containing dams or bodies of water should be widely publicly promoted; and 
  • the feasibility of conducting Home Safety Parties in rural towns to determine whether they would be a successful forum for educating carers and disseminating information on appropriate safety measures for children.

Victorian State Coroner Graeme Johnstone and Victorian Coroner Phillip Byrne, in findings handed down in 2004[2] and 2005[3] respectively, emphasised that the recommendations should be fully supported by all relevant agencies.  Coroners Johnstone and Byrne also detailed the measures already taken by Victorian agencies and organisations to address the issues.

Coroner Byrne commented:

  “The approach taken by Play It Safe by the Water in relation to toddler drowning in private swimming pools and spas appears to be a good model to address the problem of toddler drownings in rural waterways.  Life Saving Victoria were contacted by this Office to provide further information on the proposed campaign they developed for funding in 2003.  LSV advised that they have developed a public awareness campaign based on the Keep Watch program around the issue of carer supervision, child safe play areas, learning resuscitation and taking children to water familiarisation classes.  LSV hope to achieve this using rural and regional based media such as local newspapers, radio spots, television and billboards.  LSV also proposed to liaise with local Rural Safety Action Groups and attend rural and regional shows, race days and field days.  Funding is urgently required to implement this strategy for the 2005/2006 summer period.

  I am confident that if these strategies are pursued that a similar reduction in toddler drowning in rural waterways can be achieved like has been demonstrated in relation to toddler drownings in private swimming pools and spas.”[4]

In August 2005 the Victorian Farmers Federation released a report from a pilot program “Child Safe Play Areas Program”[5] addressing with relevant sections of the community the need for safe play areas on rural properties and how to achieve those safe areas.  This report recommends continuation of the program. 


The tragic death of the child highlights the need for consideration in Tasmania of prevention strategies as the 2007/2008 summer season approaches. 

Information held by the Coroners Office indicates that the child’s death is the second death in Tasmania of a young child in a dam since 2002.  In the context of Tasmania’s rural population and thus the potential for the occurrence of further similar preventable deaths, I would recommend as follows:

(a)  That relevant Tasmanian agencies and organisations consider the need for strategies, including public awareness campaigns, that specifically aim to reduce the risk of young children drowning in water on rural properties.

(b)  In determining strategies reference should be had to the recent Victorian studies, reports and initiatives in this area.

In the meantime I would urge all those supervising young children on rural properties in proximity to water to adopt the following measures:

1.  Ensure constant or near constant supervision of the child.

2.  Be aware that a child can travel a considerable distance in a short time and often are attracted to bodies of water.

3.  Ensure a safe play area for the child with adequate barriers.

4.  Maintain, if practical, secure fencing around dams.

5.  Be aware that a child in company of another similar aged child does not mean that they will protect each other from danger.

6.  Be aware of and remove any objects in the vicinity of the water that could tempt a child to enter the water.

7.  Eliminate water hazards when they are not in use eg. cover tanks and empty troughs. 

I wish to conclude by conveying my sincere condolences to the deceased’s family for the tragic loss of his young life. 

DATED: Tuesday, 9th October 2007 at Hobart in the State of Tasmania. 

Olivia McTaggart


A copy of this finding will be sent to:

·  Attorney General

·  Minister for Local Government

·  State and Chief Coroners

·  Royal Lifesaving Society Australia

·  Commissioner for Children Tasmania

·  Tasmanian Farmers and Graziers Association

·  Paediatric Mortality and Morbidity Sub-Committee

·  Kidsafe Tasmania

·  Country Women’s Association of Australia

[1] National Coroners Information System, July 2000 to July 2007

[2] Record of Investigation into Death of Lane Catlin, No 432/04, 4th August 2004

[3] Record of Investigation into Death of Gordon Ayre, No. 3509/04, 11th February 2005

[4] Child Safe Play Area Program Final Report, supra, page 5

[5] Child Safe Play Area Program Final Report, Unintentional Drowning: Toddlers in Dams, Victorian Farmers Federation, August 2005