Coronial Inquests: A Study on Children Drowning in Swimming Pools

Running head: CORONIAL INQUESTS.
Coronial Inquests
Name of Student
Institutional Affiliation

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Background Information
The coronial process is a systematic way of handling reported deaths that occur under
unusual or unnatural circumstances. The process begins by reporting of the unexpected death
to the state coroner, an investigation is conducted, and the results of the cause and
circumstance of death are exposed to the family and friends (Bugeja, Woolford, Willoughby,
Ranson, & Ibrahim, 2017). Unusual deaths that should be reported may include the death of
people in custody, death of a person 24 hours of admission or discharge, people who are in
the medical facility or drug addicts being treated. The coroner ensures investigations are done
and decides the need for an inquest and conducts a hearing (Wallis, Watt, Franklin, Nixon, &
Kimble, 2015).
Introduction
A coronial inquest is a proceeding held to establish the reason of death and the situation
under which an unusual death occurs. It is conducted by a judicial officer who is termed as a
coroner. It’s a public proceeding that aims to find answers to reportable fatalities and prevent
future similar incidences. Before the inquest, the coroner can request autopsy reports to
determine the precise reason of death in cases where the cause cannot be explained from the
history given and the police report from the scene. Witnesses usually are called upon to give
evidence. Functions of an inquest are to provide suggestions to prevent similar deaths in the
future and determine any suspicions of a criminal offense. This case study narrows down on
coronial inquests about children drowning in swimming pools. The hearings aim to determine
the cause of death whether it is drowning or if there were any suspicions, provide vivid
evidence and police reports then come to a conclusion stating the recommendations to avoid
any future child drowning incidences.

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Application of coronial process
In the case study about children drowning in pools, the coronial process has been applied to
the latter end. According to the Rockhampton inquest on a 10-year-old child died from
drowning in a pool. The case was reported and investigated upon. During the investigation,
the coroner decided to conduct an inquest. In the hearing, witnesses were called upon to give
an account of the happenings of the day to as evidence. All events were investigated to
eliminate suspicion of anyone being involved in the death. An autopsy report wasn’t done
since the cause of death was evident (Coroners Act s7). The child was under supervision by
family and was warned against the danger spots. After collection and hearing of evidence,
risks assessment was done, and recommendations were made to prevent similar deaths
occurring in the future. Some families request for an inquest in case they want to enlighten
other families and prevent the occurrence of similar incidence. According to Sebastian’s
inquest, the parents and coroner demanded a hearing to know the cause and circumstance of
death, the risk factors that precipitated and the future changes towards promoting safety. Risk
factors of the location of the pool were assessed and recommendations made in line with the
colonial process. In the Jean-Marie inquest, investigations were carried out after the case was
reported following an autopsy. A coronial inquest was carried out to discover anything
suspicious occurred surrounding the situation. Witnesses gave the evidence, and a police
report examining the scene and the causative factors were identified. Areas of weakness were
spoken out and recommendations made.
Common causative factors
The common factors between the three inquests based on causes of death are; the child was
not a competent swimmer, not adequately supervised and had a disability of being unable to

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understand and follow instructions carefully. The contributing factors of the incident include;
ignorance of the child, failure of the owner of the pool to assess the risks present, the
situation of the inflatables and due to incompetent and inadequate staff to educate the clients
and supervise the children within. (Rockhampton inquest). Other causes of death are due to
negligence (Sebastian inquest). The death could have been prevented if there was a fence
obscuring the child from accessing the pool. The father of the child in the Jean-Marie inquest
fell asleep and took his eyes off the child. This was on top of the presence of a faulty gate that
could not close completely. This act of negligence caused the death of the child. Another
common cause of death is when the parent or guardian fails in the responsibility of protecting
the child. This was contributed when the guardian transfers responsibility to strangers and
forgets or in the case of Brisbane inquest where the parent is suspected to have been on drugs
the previous night. In the outcomes, the children died unusual and sudden deaths that could
have been prevented if the responsible adults performed their roles (Weber, & Pickering,
2014). The hearings conducted identified the weakness that caused the incidences, some of
which could be prevented and some needed recommendations to be implemented to avoid
similar happenings. In the outcome, the family members were consoled and explained to the
findings of the investigations on the causes of the deaths and what went wrong (coroners act
s46).
Public health perspective on prevention
Public health is a field that deals with prevention of occurrence of disease, improving quality
of life and lengthening life through assessing of risk factors available in the society and
rectifying them. The above deaths could have been prevented from my public health
perspective. By applying the risk prevention policy, the faulty inflatables could be tasted and
rectified before being used and the malfunction identified and client education given out on
how to use them, the risks involved and the degree of supervision required for children. The