NT coroner determines ‘systemic failures’ behind toddler’s septic drowning in remote community
A series of failures – dubbed ‘systemic’ – contributed to a toddler’s horrific drowning in a septic tank in the Territory, the Coroner has determined in her newly-released findings.
A toddler’s drowning in a septic tank in the NT was the result of a series of “systemic failures” by government departments that “sat on their hands,” the Coroner has determined.
The failures were outlined in the findings from the inquest into the death of Kumanjayi Fly, delivered by NT Coroner Elisabeth Armitage.
The toddler was just two years old when he was pulled out of a septic tank he’d fallen into playing in the yard of his family’s Mt Liebig (Watiyawanu) home on March 29, 2023.
During the inquest into his death, held in Alice Springs October last year, the court heard how his uncle Roderick Daniels jumped into the tank without protection to retrieve his nephew.
Tragically, when Mr Daniels retrieved the young boy, he was already brain dead, the inquest heard.
The toddler was taken to Alice Springs Hospital and later transferred to the Women’s and Children’s Hospital in Adelaide, where on April 3, 2023, his life support was turned off.
“He had only just turned two. His family have suffered an unfathomable loss,” Ms Armitage wrote in her findings, delivered on Friday.
In her findings, Ms Armitage details how the family’s home in the community, located roughly 325km west of Alice Springs, was due to be upgraded as part of the government’s Room to Breathe program.
As part of the upgrade, a plumbing report – commissioned four years before the toddler’s tragic death – identified the septic tank as non-compliant with Australian standards and in need of an upgrade.
During the inquest last year, evidence was heard from senior public servants such as then-Room to Breathe project manager Stuart Munnich, who – under oath – told the court he doesn’t know “what it means when they say they’re non-compliant,” when asked about the plumbing report by counsel assisting Fiona Kepert.
George Timson, who was the then-Room to Breathe program director, told the court he had not even seen the relevant plumbing report, despite stern questioning from Ms Armitage, who asked: “you were the program director. How is it that that report could be commissioned, paid for, obtained, and not come to your attention?”
“It should have done … I guess our processes weren’t that good at the time to make sure that happened,” Mr Timson responded.
Mr Timson is a senior director at the Housing Office, while Mr Munnich is an assistant infrastructure director with the Department of Planning, Infrastructure, and Logistics (now Department of Logistics and Infrastructure).
Ms Armitage did not recommend any charges be laid against any party involved in the septic tank upgrade in her findings, nor did she accuse Mr Munnich or Mr Timson of wrongdoing in her findings.
In her findings, Ms Armitage was scathing of the NT government housing department (as she referred to them) due to their inability to action the 2019 plumbing report.
She outlined a series of “systemic failures” within the department, in which the septic tank upgrade at the family home – on which $140,000 was spent on just pumping out wastewater and replacing the drains between 2016 and 2022 – was deferred, handballed, and finally, “swept under the rug,” as one email tendered to the court claimed.
“The relevant Government departments knew that the septic system at (the Fly family home) was failing and had been failing for many years and numerous experts had recommended that it be upgraded or replaced,” Ms Armitage wrote.
“Similar concerns have been raised about other homes across numerous communities.”
In her findings, Ms Armitage noted an audit conducted by the NT government determined there were 900 septic tanks Territory-wide at public housing properties alone.
“Instead of addressing this widespread safety issue, the relevant government departments sat on their hands and did, effectively, nothing,” Ms Armitage wrote.
“The government departments did not prioritise safety and Kumanjayi tragically passed away in traumatic circumstances.
“Had action been taken when it should have been taken, the septic system at (the Fly family home) should have been upgraded and/or replaced and this tragedy would likely have been avoided.”
Days before the inquest was due to start last year, the Department of Logistics and Infrastructure chief executive Louise McCormack issued a public apology to the Fly family.
In the apology, delivered October last year, the department said it will “act on all findings and recommendations handed down from the inquest”.
Ms Armitage made nine recommendations to the department, one of which is for secondary safety shields to be fitted on septic tank access points in public housing.
In December last year, when the inquest resumed, the court heard how the department is due to install new safety shields on septic tanks in communities across the NT.
NT Health got four recommendations from Ms Armitage, one of which also included introducing septic tank safety shields.
On Tuesday, DLI acting chief executive Gemma Lake said the department will now “consider all findings and recommendations handed down”.
Originally published as NT coroner determines ‘systemic failures’ behind toddler’s septic drowning in remote community
