PUBH300 S1-2018 Coronial Inquests: Public Health Perspective

This case study analyzes coronial inquests related to child drownings from a public health perspective, focusing on the application of the coronial process, common factors contributing to the deaths, and failures in prevention efforts. It examines inquests like the Rockhampton, Sebastian, and Jean-Marie cases, identifying factors such as inadequate supervision, lack of swimming competence, and negligence. The study discusses how public health principles, including risk prevention and community education, can contribute to preventing similar incidents. It also explores the reciprocal relationship between the coronial process and public health, emphasizing the importance of implementing recommendations from inquests and the role of public health in strengthening legal frameworks. The conclusion highlights the significance of the coronial process in identifying risks, implementing preventative measures, and supporting affected families.

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

CORONIAL INQUESTS.
2
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.

CORONIAL INQUESTS.
3
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

CORONIAL INQUESTS.
4
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

CORONIAL INQUESTS.
5
staff working at the pool with no qualifications could be trained first on how to supervise and
protect children. According to public health perspective, the management should equip the
staff with knowledge of life-saving techniques, digital monitoring around the pool and the
expertise on the use of devices within. Children with disabilities whether minimal or those
under medical treatment or very young children should not be left alone (Franklin, Pearn &
Peden, 2017). They should be enrolled in groups where they can be taken care of by
specialists who understand their situation. Public health incorporates homestead risk
avoidance such as ensuring critical point such as pools are appropriately fenced out of reach
of children. Irresponsible parents who are on drugs should not be allowed to raise children on
their own, and this could prevent the deaths and future incidences (Haynes, Coates, van den
Honert, Gissing, Bird, de Oliveira, ... & Radford, 2017). Recreational places such as pools
should be assessed periodically for any risks, mostly before summers. The pools in
homestead should also be monitored to ensure they are out of reach of unsupervised children
and the apparatus are not faulty.
Coronial process contribution to public health
Coronial process contributes largely to public health practice due to the recommendations
that are made during the inquest. Introduction of life-saving societies where society receives
education on life-saving procedures of how to save drowning people, the swim and keep
teachings and provide resuscitation equipment to the firms this promotes first cause of action
in cases of emergency and can preserve life in the society (Coroners Act s45). Creating safety
alerts contributes to public health as the population will be aware of the risks at hand (Bugeja,
Ibrahim, Ferrah, Murphy, Willoughby & Ranson, 2016). This alert comes after a risk
assessment of the environment by carrying out periodic inspections and identifying the
dangerous areas hence enabling people to adjust and be careful. Safety measures should be
done and evaluation of the condition of pools before summer holidays before client’s report.

CORONIAL INQUESTS.
6
The pool builder certifiers should be followed and ensure proper fencing and gates are
established instead of leaving the responsibility to the owners as in the Jean-Marie inquest.
There should be establishment of entry and exit rules (Bugeja et al., 2016). Children should
not enter without responsible guardians, and they should be monitored through the stay the
child was not monitored in the Rockhampton inquest hence the death.
In the contribution to public health, there should be implementation of recommendations like
the establishment of effective monitoring techniques where all children can be monitored
from one point by use of technology such as digital photographs of what’s happening hence
ensuring they are safe. Enroll children and people who don’t have swimming skills for
practice to avoid pool accidents as they can swim out (Bugeja, & Dwyer, 2016). The staff
employed must have qualifications and expertise as far as safety is concerned. The team
should also be adequate in number depending on the size of the pool, and the population can
hold A person or organization should be held responsible in case issues of negligence occurs
and they shall face penalties to act as an example to the society in general. Recommendation
on proper communication during an investigation. Witnesses should give a clear and vivid
explanation of the incidence so as appropriate strategies may be put in place to avoid future
happenings thus preserving human health. Recommendation to the council to perform tasks
such as pool fencing to promote the safety of the public at large.
Public health contribution to the coronial process
Public health contributes significantly to coronial process in that it helps the law to achieve
its goals. Public health perspective ensures the recommendations of the coronial process are
put into place. The perspective has its aims that strengthen the laws (Sutherland, Kemp,
Bugeja, Sewell, Pirkis, & Studdert, 2014). The standpoint of ensuring life is preserved, and
risks are eliminated it contributes to fastening the policies in place on protection and rights of

CORONIAL INQUESTS.
7
the society. A policy is a stated suggestion, but public health focuses on the strategies put in
place and the manpower to ensure safety and prevention from unexplainable deaths such as in
the Jean-Marie inquest. Evidence-based public health helps to expand research in strategies
for preventing unusual deaths (Haebich, 2015). Preventive measures are conducted in the
society to assess the general condition and the safety of everyone in general avoiding deaths
like in the Sebastian inquest. Individuals are enlightened on the safety measures and the
rights and rules of practice hence they should be able to report any occurrences that are
outside the code of conduct. The happenings in the Sebastian inquest, Jean-Marie and
Rockhampton inquests are in line with the policies of public health and safety (Abawi, &
Brady, 2017). Ensuring life of people is preserved and those that fail to attend to it face the
consequences. Policies are to promote long-term health effects with low cost and providing
positive outcome of disease hence prolonging life. Its rationale is to improve the general
health of the society by the necessary amendments and implement monitoring strategies
preventing unusual deaths and fires in the nation at large.
Conclusion
Colonial process helps the society in general to identify the risks in place and ways of curbing
them. on the other side, the recommendations that arise during a colonial inquest are
implemented hence promoting health of the public in general. This focuses on the objectives
of health of improving quality of life and prolonging life. The pieces of evidence collected
during the investigation process identifies the individuals who are indirectly or directly linked
to the incidence and ensure necessary actions are taken upon them. It also systematically
helps families to get over stressful situations by explaining the cause of unusual death or
fires. It helps them understand and recover from the trauma by explaining the origin,
circumstance and by alleviating the suspicions that someone was involved.

CORONIAL INQUESTS.
8

CORONIAL INQUESTS.
9

CORONIAL INQUESTS.
10
References
Abawi, Z., & Brady, J. (2017). Decolonizing Indigenous Educational Policies. Emerging
Perspectives: Interdisciplinary Graduate Research in Education and Psychology,
1(1), 20-30.
Bugeja, L., & Dwyer, J. (2016). Enabling public health and safety through the coroners' death
investigation system: The principles and practice of the coroner’s prevention unit.
Grief Matters: The Australian Journal of Grief and Bereavement, 19(2), 47.
Bugeja, L., Ibrahim, J. E., Ferrah, N., Murphy, B., Willoughby, M., & Ranson, D. (2016).
The utility of medico-legal databases for public health research: a systematic review
of peer-reviewed publications using the National Coronial Information System.
Health research policy and systems, 14(1), 28.
Bugeja, L., Woolford, M. H., Willoughby, M., Ranson, D., & Ibrahim, J. E. (2017).
Frequency and nature of coroners’ recommendations from injury-related deaths
among nursing home residents: a retrospective national cross-sectional study. Injury
prevention, injuryprev-2017.
Coroners Act 2009 s45(2)
Coroners act 2009 s46(1)
Coroners Act 2009 s7(3)
Franklin, R. C., Pearn, J. H., & Peden, A. E. (2017). Drowning fatalities in childhood: the
role of pre-existing medical conditions. Archives of disease in childhood,
archdischild-2017.
Haebich, A. (2015). Somewhere between fiction and non-fiction New approaches to writing
crime histories. TEXT, 28.
Haynes, K., Coates, L., van den Honert, R., Gissing, A., Bird, D., de Oliveira, F. D., ... &
Radford, D. (2017). Exploring the circumstances surrounding flood fatalities in

CORONIAL INQUESTS.
11
Australia—1900–2015 and the implications for policy and practice. Environmental
Science & Policy, 76, 165-176.
Inquest into the Death of Jean-Marie JeremieYannick Zaza [2009] Office of the State
Coroner (Queensland) 16/08
Inquest into the Death of a child at Rockhampton [2010] Office of the State Coroner
(Queensland) 2007/145
Inquest into the Death of Sebastien Yeomans [2015] Coroners Court of New South Wales
2012/157613
Sutherland, G., Kemp, C., Bugeja, L., Sewell, G., Pirkis, J., & Studdert, D. M. (2014). What
happens to coroners’ recommendations for improving public health and safety?
Organisational responses under a mandatory response regime in Victoria, Australia.
BMC public health, 14(1), 732.
Wallis, B. A., Watt, K., Franklin, R. C., Nixon, J. W., & Kimble, R. M. (2015). Where
children and adolescents drown in Queensland: a population-based study. BMJ open,
5(11), e008959.
Weber, L., & Pickering, S. (2014). Counting and Accounting for Deaths of Asylum Seekers
en Route to Australia.