Coroner's Court of Western Australia

Inquest into the Death of Lachlan James MITCHELL

Inquest into the Death of Lachlan James MITCHELL

Delivered on :30 May 2018

Delivered at : Perth

Finding of : Coroner Linton

Recommendations :Yes

Recommendation 1
I recommend that the Honourable Minister for Child Protection and Community Services give consideration to amending the relevant legislation in Western Australia to exclude homes with a swimming pool, outdoor spa or jacuzzi from being used to operate a family day care service where children under the age of five are admitted to care, which should come into effect immediately given the high level of risk of drowning.

Recommendation 2
I recommend that the Honourable Minister for Child Protection and Community Services give consideration to amending the relevant legislation in Western Australia to exclude new family day care educators from being approved to operate a family day care service from a home with a swimming pool, outdoor spa or jacuzzi.

Recommendation 3
I recommend that the Honourable Minister for Child Protection and Community Services give consideration to amending the relevant legislation in Western Australia to require that where an existing family day care educator operates a family day care service from a home with a swimming pool, outdoor spa or Jacuzzi (which will only be for children over the age of 5 years) the approved provider must physically inspect the property monthly to ensure that the safety barrier to the water hazard is functioning effectively and there are no climbable hazards in proximity to the fencing. The need for direct supervision in proximity to the water hazard must also be reiterated to the educator during each inspection.

Recommendation 4
I recommend that the Honourable Minister for Child Protection and Community Services give consideration to requiring all family day care educators to have a fixed landline installed at their premises so that it is available to contact emergency services in the case of an emergency.

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased at the time of his death was in the care of a small family day care service operated from a home. The carer had child care qualifications.  Prior to January 2015 she had worked at mainstream child care centres.  Sometime in November 2014 the carer was approved and registered to operate as a family day care educator and was licensed to care for up to four children at a time.  She was registered with a family day care service, Communicare, under the Family Day Care National Law.

On Monday 9 November 2015 the deceased’s mother dropped the deceased at the day care service where there were two other children being cared for that day. At about 9.00 am the deceased and the carer were outside while the other two children remained inside the house.  The carer returned inside the house to tend to one of the children.  The carer later realised the deceased did not follow her into the house and he had remained outside unsupervised.

The carer returned outside to look for the deceased and has located him floating face down on the surface of the swimming pool near the steps of the pool. The carer pulled the deceased from the water and immediately commenced CPR.  The deceased bought up water and vomit.  The carer carried the deceased into the house and continued to perform CPR where the deceased continued to bring up water and vomit.  The carer was unable to locate her mobile telephone and stopped doing CPR and ran from her house to get help.  She ran to her neighbour and asked them to call for an ambulance.  An ambulance was called and one of the neighbours returned with the carer to her house. The neighbour has continued to perform CPR on the deceased.

When ambulance officers arrived at the house they observed the deceased to have no apparent injuries but was unresponsive, grey/white in colour and cold, with a temperature of only 30.5°C. The deceased was transported by ambulance to the Joondalup Health Campus where he was still asystolic on arrival and it was estimated he had been immersed and/or in cardiac arrest for at least 30 minutes.  The deceased was transferred to Princess Margaret Hospital in the afternoon.  The following day brain stem testing was completed in the presence of the deceased’s parents on two occasions and brain death was confirmed.  The deceased was taken off life support and died.

The Coroner made four recommendations relating to improving safety at family day care facilities where family day educators operates a family care service from a home.

Catch Words : Family Day Care Service : Drowning : Accident.


Last updated: 4-Sep-2018

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