A mother took a phone call. Nine minutes later, her son was found face down in the pool

A toddler who fell into a Crown Towers pool had been floating face down for more than nine minutes before he was spotted by an adult, an inquest has heard, as the coroner links poor supervision to the drowning of 43 children in Victoria over 14 years.

Coroner Sarah Gebert found children aged one to two were most at risk of drowning and represented the highest number of drownings since 2010. She emphasised the need for parents and carers to be vigilant when supervising children around water.

Even the shallowest of pools can be a drowning hazard for very young children.Credit: Peter Braig

The finding comes after a coronial investigation into the death of a two-year-old boy at Crown Towers hotel on November 19, 2021.

Gebert said the boy, who cannot be named for legal reasons, two siblings and two cousins were in the pool area of the hotel as the two-year-old’s mother took photos and videos on her phone. No lifeguards were present or staffed at the hotel at the time.

“Shortly before the pool closed for the evening, [the boy’s mother] answered a phone call and then remained looking down at her phone for several minutes whilst seated in the toddler pool,” Gebert said. “During this time, she did not notice [the boy] moving from the toddler pool and falling into the adult pool, where he drowned.

“CCTV showed that by the time another pool patron noticed [the boy] unresponsive in the water, he had been floating face down in the adult pool for over nine minutes.”

The two-year-old died in the Royal Children’s Hospital eight days later.

“[The boy’s] tragic death and the circumstances of his drowning highlight the need for close supervision of young children, especially in and around pools,” Gebert said.

As part of her investigation, the coroner said she had sought to understand whether a lack of supervision contributed to drowning deaths of children in Victoria.

She found that from January 1, 2010, to March 31, 2024, 47 children aged four and under had drowned in Victoria. Of the 47, inadequate supervision was a factor in 43 drownings.

Children aged one represented the highest age group of drownings, with 16 deaths, followed by two-year-olds, with 11 deaths.

Gebert said the vulnerability of these age groups was, in part, because children aged one to two become more mobile, and were curious and unpredictable.

Safety messages consistently repeated by authorities, including the Royal Children’s Hospital, Kidsafe Victoria and Life Saving Victoria

• Supervision means constant visual contact, not the occasional glance.
• Adults should actively supervise children, even if the child can swim.
• Supervising adults should avoid all distractions, including using a phone or answering the door.
• Do not leave older children (under the age of 16) to supervise younger siblings.
• Children under five years must be within arms’ reach, and children under 10 must be clearly and constantly visible and directly accessible.

The findings also follow the death of two-year-old Lara boy Luka, who drowned in a dam near his home in June after he had wandered off from his mother.

In May, a court convicted the Victorian Education Department and fined it $100,000 for breaching workplace safety laws over the death of year 2 student Cooper Onyett, aged eight, who drowned at a Port Fairy swimming pool on the last day of his school camp two years earlier.

Earlier inquests, Gebert found, had also raised issues, including that bodies of water were a temptation to young children because they represented a fun activity and adventure, but children did not adequately understand the dangers of water.

The use of life vests or other buoyancy aids were not a substitute for close, focused and active supervision, she noted, and adults should not assume someone else is supervising the child.

“Parents therefore need to be vigilant and exercise adequate supervision of children in and around bodies of water, and a brief lapse of vigilance can have tragic consequences,” the coroner said. “Children can drown in as little as 20 seconds, in shallow water (only a few centimetres deep) without making any noise.”

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