Inquest into how toddler drowned in Mt Liebig septic tank ends with shock admissions from public servants
A septic tank report has laid bare government dysfunction at an inquest into a toddler’s tragic death – with some public servants making shock admissions about it.
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October 18: An inquest probing how a toddler tragically drowned in a septic tank has revealed a public servant didn’t understand the term “non-compliant” when it was used to describe the septic system in a report – while the project director did not even see the report.
The inquest into two-year-old Kumunjayi Fly’s death concluded in the Alice Springs Local Court on Friday, with public servants again facing tough questions – particularly around their handling of a 2019 report which identified issues with a septic tank, three years before the fatal incident.
The boy fell into his grandmother’s septic tank March 29 last year in the remote community of Mt Liebig.
He was taken to Adelaide’s Women’s and Children’s hospital, where he died April 3.
Taking to the stand first was former Room to Breathe project manager Stuart Munnich.
Mr Munnich offered his condolences to the family, who stared silently back at him, and watched him intently as he answered questions.
Counsel-assisting Fiona Kepert questioned Mr Munnich on the plumbing report which identified the grandmother’s septic system as “non-compliant”.
“I don’t know what it means when they say they’re non-compliant,” Mr Munnich quietly said.
“In hindsight, looking back now, I should have referred that report to somebody with the technical, technical expertise, or to senior management.”
Mr Munnich agreed he read the report in 2019 – but “not in detail”.
Email chains were also presented to the court, which showed Mr Munnich raising the issue of septic system improvements.
But he later changed his stance and said the system wouldn’t need to be upgraded.
He gave an account of tough deadlines and travel schedules, and said he didn’t have specific training on septic systems nor their safety.
Mr Munnich is now an assistant infrastructure director with the Department of Planning, Infrastructure, and Logistics (now Department of Logistics and Infrastructure).
Then-Room to Breathe program director George Timson also gave evidence.
He told the inquest he had never seen the 2019 report, which Coroner Elizabeth Armitage pressed him on.
“You were the program director. How is it that that report could be commissioned, paid for, obtained, and not come to your attention,” she asked.
“It definitely did not come to my attention,” he responded.
“It should have done … I guess our processes weren’t that good at the time to make sure that happened.”
He corroborated Mr Munnich’s point of tight deadlines, and said there “was a high demand for many things to happen simultaneously” as a possibility of why the report slipped his sight at the time.
Mr Timson is now a senior director in the housing program office.
The inquest previously heard the grandmother’s septic systems should have been upgraded in line with a Room to Breathe house extension.
In the afternoon, housing program general manager Dwayne McInnes spoke about the changes which had occurred within the government since the tragedy.
He said he did not see the 2019 report until after the incident.
He agreed there was a “failure” when the septic tank upgrades were not completed at the grandmother’s home, and agreed it was “unacceptable” works did not occur after issues were identified in the 2019 report.
Department of Logistics and Infrastructure portfolio management director Peter Lilliebridge said there were now preventive maintenance programs on septic tanks being undertaken by the government.
He said an audit was also underway of homes in remote communities which would be undertaken by the next financial year.
Mr Lilliebridge, Mr Timson, and Mr McInnes all gave their condolences to the family.
The coroner will release her findings at a later date.
Home still hazardous 17 months after septic tank tragedy
October 17: The home where a toddler drowned in a septic tank also has an airconditioning unit which is “precariously balanced” and “not very safe”, the inquest into the boy’s death has heard.
The inquest into Kumunjayi Fly’s death entered its fourth day in the Alice Springs Local Court on Thursday, where public housing safety was front and centre.
The toddler fell into the septic tank in his grandmother’s home in Mt Liebig March 29 last year.
Four days later, he died in the Adelaide Women’s and Children’s Hospital.
Answering questions in the morning was Department of Housing acting deputy chief executive Brendan Boyce.
Sitting in the gallery again was the boy’s family, who silently watched on.
Under questioning from counsel-assisting Fiona Kepert, the inquest heard how the home had airconditioning systems described as “precariously balanced” and “not very safe”.
Images of the airconditioning systems were shown, and Mr Boyce agreed with Ms Kepert’s description.
However Mr Boyce countered the airconditioning systems were not installed by the Department of Housing, and “should” be removed before new tenants moved in.
“There is work for us to potentially support that tenant in addressing the airconditioning installation that they’ve chosen to put up between inspections or without us knowing,” he said.
He said “all new builds will contain reverse cycle airconditioning”.
“Airconditioning systems will be installed as part of a program that DLI (Department of Logistics and Infrastructure) will be able to speak to in more detail,” he said.
Previously, the inquest heard how after the boy drowned, works were completed to make the septic system safe.
Under questioning from lawyer Bill De Mars, representing the family, Mr Boyce agreed Mt Liebig had the “less desirable” type of septic system.
But for further clarity, Mr Boyce referred Mr De Mars to the Department of Logistics and Infrastructure, which he said was best suited to provide advice on septic tanks, for “detailed” answers.
Also giving evidence was Simone Persson from the National Indigenous Australians Agency and Tracey Ward from the Department of Health.
Ms Persson discussed the Commonwealth’s involvement in funding remote homes.
She said upgrades completed to the grandmother’s home were funded by the Northern Territory government.
Earlier, the inquest heard how under Room to Breathe upgrades, the grandmother’s septic system should have been upgraded.
On the first day of the inquest, issues with the grandmother’s septic system were first identified in a 2019 plumbing report.
The final of the inquest is on Friday, October 18.
Septic tank which claimed boy’s life had lid so loose ‘it spun like a coin’
October 16: The cover of a remote community home’s septic tank – which a toddler tragically drowned in – had a lid so loose it “spun like a coin”, an inquest has heard.
The inquest into how Kumunjayi Fly drowned in his grandmother’s home’s septic tank in Mt Liebig entered its third day in the Alice Springs Local Court on Wednesday.
Appearing via videolink from Mt Liebig School, principal Lawrence Kelly cast his mind back to March 29, 2023 – the day Kumunjayi fell into the tank.
Earlier, the inquest heard from Roderick Daniels, the boy’s uncle, who jumped into the tank without any safety equipment to get his nephew out.
Mr Kelly said he arrived at the scene to see Mr Daniels holding his nephew.
The septic tank lid was “30 to 40cm away” from the tank, which was “full to the brim with water”, Mr Kelly told the inquest.
Mr Kelly said he was assisting with clearing the boy’s airway before the ambulance arrived and took him away for further treatment.
Mr Kelly said he later returned to the grandmother’s house, where shire manager Stuart Miller tried to put the lid back into place on the septic tank.
“(Mr Miller) went to tap it with his foot, once he got the lid in position, it spun like a coin and opened up again,” Mr Kelly said.
“It spun up like a coin, it went to a 90 degree angle and was open again.
“I actually thought he might fall in.”
Sitting in the gallery, family members murmured in agreement at his comments.
Mr Kelly also said that before the death, the neighbouring home to where the incident occurred also had its share of plumbing issues.
“There was an ongoing issue there for a long time with the septic, and they actually moved the people out of that house,” he said.
After the incident, Mr Kelly said contractors had been employed to make sure the school’s septic tanks were not a hazard.
Gideon Azar, who authored a report after the incident, also spoke on day three.
Appearing via videolink from Queensland, Mr Azar blamed the ‘poor condition of the cover’ for the boy’s death.
Peter Rogers from the Department of Health also appeared via videolink and said the septic tank was “non compliant” with the Australian standards.
Mr Rogers was part of a team upgrading the grandmother’s house as part of the Room to Breathe Program.
“The original septic tank system, the lock-eight, was installed around 1998-1999 under a septic tank upgrade program associated with the National Aboriginal Health Strategy program,” he said.
“So if you look at the Australian Standard, which quotes the life expectancy, the estimated life expectancy of septic tank systems is about 15 years.
“So from around 2012, 2013 onwards, that tank would certainly be under question about its integrity.”
Under questioning from counsel-assisting Fiona Kepert, Mr Rogers agreed by 2022 the tank was “well past its capacity to continue”.
Earlier in the day, Thomas Manning from the Department of Housing was in the stand.
Through interjections from lawyers Michael McCarthy (representing the Department of Housing and Department of Health) and Tom Grace (representing the Department of Logistics and Infrastructure), Mr Manning was questioned by Coroner Elisabeth Armitage and Ms Kepert on the condition of homes in Mt Liebig.
Before the inquest began, Ms Armitage, along with the lawyers and departmental representatives, visited Mt Liebig.
Referring to the visit, Ms Armitage and Ms Kepert questioned Mr Manning whether he would live in one of the homes they visited.
Mr Manning quietly said he would.
“Even with a broken toilet?” Ms Armitage asked.
Ms Kepert said the Mt Liebig home in question had a leaky toilet, a bedroom which had a leak from the roof, and multiple faulty sockets – one of which “sparks” – and a stove which “shorts the power”.
Mr Manning said there were multiple work orders which would be “immediately raised”.
Mr Grace pulled a May 23 and July 16 department report which he said contained no record of the issues Ms Kepert raised.
“I just wanted to let your honour know we are preparing a response to this matter,” he said.
Referring to the visit, he said “I didn’t go and turn the stove on to see if the power tripped”.
Responding to Mr Grace, Ms Armitage agreed she didn’t check the faults herself.
“I didn’t go and flush the toilet,” she said.
‘I tried to save him’: Uncle jumped into septic tank to rescue toddler
October 15: An uncle who pulled his brain dead nephew out of a septic tank in a Red Centre remote community says he “vomited up” after he jumped into the tank with no protection equipment on at all.
The inquest into how two-year-old Kumunjayi Fly tragically died in a septic tank in Mt Liebig resumed in the Alice Springs Local Court on Tuesday, with day two thrusting maintenance workers into the spotlight.
The boy fell into the tank on March 29 last year when he was playing in the backyard of his grandmother’s house.
Four days later he died in Adelaide Women’s and Children Hospital.
He was brain dead when he was pulled from the tank, the inquest heard.
Taking to the stand on the second day of the inquest was his uncle Roderick Daniels, who pulled him from the tank.
He softly told the inquest how he jumped in without safety equipment to grab the boy.
“I went in without protection … after I went home, had a shower, vomited up,” he said.
“I tried to save him.”
He said he wanted to see workers who completed work on septic tanks to “double check the bolts” after they were done.
“For our children’s safety; plumbers need to double check the bolts after they’ve finished their job, because sometimes they leave bolts loose,” he said.
Mr Daniels said he was first alerted to something being wrong when he was fixing his car and heard a scream.
He said he ran over straight away, and when he got there the septic tank lid was lying a few metres away.
Earlier in the morning, the toddler’s family slowly trickled into the court to hear building surveyor Paul Hinkly questioned.
Before the toddler’s death, an extension was completed on his grandmother’s house, which Mr Hinkly signed off on as the surveyor.
The first day of the inquest revealed a November 2019 plumbing audit identified the home’s septic systems needed upgrading, which should have been part of the house extension.
At the stand, Mr Hinkly said he was “flabbergasted” the report hadn’t been followed and accused “someone in the government” of choosing to not upgrade it.
“I can’t understand why someone in the government didn’t flag (the septic system upgrade),” he said.
But under questioning from lawyer Tom Grace, representing the Department of Logistics and Infrastructure, Mr Hinkly agreed his concerns came after he’d signed off on the works – without the septic tank upgrade completed – upon hearing evidence at the inquest.
Under examination by Mr Grace, Mr Hinkly admitted he did not undertake an on-site inspection before he signed off on the extension.
Filling most of the seats in the gallery, the boy’s family silently watched on as the two butted heads.
Mr Grace suggested “it was a mistake” the 2019 report was “overlooked” and pressed Mr Hinkly on his “concerns” some government staff may be “unqualified”.
Mr Hinkly did not provide detail on when he raised these concerns or how government staff were “unqualified”.
“There are people in the government, and I deal a lot with them, and I have my doubts on what their qualifications are to a respect,” he said.
He said he took his “concerns” to ministers and relevant government bodies “over the years”.
After Mr Hinkly, author of the 2019 plumbing audit Jordi Chalmers took the stand.
Mr Chalmers told the inquest how the septic tank was “non-compliant”.
“At the time, I wasn’t expecting them to be upgraded … it was safe enough at the time when I left it,” he said.
Under questioning from Coroner Elizabeth Armitage and counsel-assisting Fiona Kepert, he said under the current code a septic tank’s size was determined from soil type and the number of bedrooms in a house.
Plumbers Rowan Clark and Tim Mitchell also spoke.
Mr Mitchell said since the incident he’d come across septic tanks in other communities which had issues.
Mr Mitchell said “we’re just told to go and do what we’re asked to do” in relation to works undertaken in Mt Liebig.
“We’ve always been told we can’t do extra work there,” he said.
The inquest continues on Wednesday.
Toddler’s harrowing death puts ‘troublesome’ septic system under microscope
October 14: Evidence at an inquest could reveal how a government department was aware of a “troublesome septic system” but did not act – a failure which led to a toddler’s horrific death in a remote Northern Territory community.
Extra chairs were brought into the old Alice Springs supreme courtroom for the grieving family of Kumunjayi Fly, searching for answers as to how the two-year-old drowned in a Mt Liebig septic tank last year.
Presiding over the inquest, Coroner Elisabeth Armitage told the court how the boy was playing in his grandparents backyard, unaware of a “troublesome septic system”.
“He should have been safe. The family did not understand that there was, in fact, a danger in that yard,” she said.
Ms Armitage said the boy fell in the tank on March 29, 2023.
He died on April 4 in the Adelaide Women’s and Children hospital.
“Within a couple of days of that tragedy, the (septic tank) lid was made secure,” she said.
“I ask, why did it cost a child’s life to make those repairs happen.”
In her opening statement, counsel-assisting Fiona Kepert revealed how a 2019 plumbing audit identified issues with the specific septic tank the boy drowned in.
The report identified multiple issues of noncompliance, Ms Kepert said, including but not limited to how “access covers were incorrect” across multiple septic tanks in the remote community.
She further detailed how at the boys grandmother house – where he was playing – the report identified the septic was non-compliant “due to the fact that the access covers are incorrect, missing bollards/protection, no distribution pit, joint putty coming adrift from the saddle riser and tank, baffles corroded”.
Ms Kepert said the home where the boy drowned was the responsibility of the Territory Government by the “department responsible for public housing”.
The property was overseen by the Department of Territory Families.
The department has since been split.
Lawyer Michael McCarthy is representing the Department of Housing and the Department of Health at the inquest.
Lawyer Tom Grace is representing the Department of Logistics and Infrastructure, formerly the Department of Infrastructure, Logistics, and Planning.
They are expected to give evidence at a later date, as well as builders who were involved with renovation projects in Mt Liebig.
Ms Kepert said there were 900 septic tanks across public housing properties in the NT, excluding homelands, schools, government buildings, police stations, and clinics.
“The risk of drowning is clearly very real and widespread,” she said.
The inquest continues until Friday, October 18.
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