When a two-year-old girl drowned in a backyard swimming pool in Katherine last year, she was unsupervised, the pool gate had been propped open, and the fence around the pool was not compliant with Northern Territory regulations, the coroner has heard.
"Baby Croker", as her family requested she be known, drowned during a backyard barbecue.
Her body was pulled from the water by two older children who found her unresponsive in the pool.
The little girl was one of a handful of young children playing in and around the pool area as adults gathered five to 10 metres away under a patio.
There were no adults in the pool or the pool area when Baby Croker died.
Over three days of evidence about the circumstances of Baby Croker's death, Northern Territory coroner Elisabeth Armitage heard better compliance and enforcement of pool safety regulations should be recommended.
"The question is, would anyone want this to happen at their next barbecue?" Giles O'Brien Hartcher, the counsel assisting the coroner, said.
"And the answer is most certainly not."
In closing submissions to the court, Mr O'Brien Hartcher urged the coroner to consider several recommendations, including that the Swimming Pool Safety Authority in the NT be better equipped to ensure compliance with and enforcement of the Swimming Pool Safety Act.
The coroner heard Northern Territory legislation did not require swimming pool fences to be re-inspected regularly and once a compliance certificate was issued to a property owner, it did not expire.
"Regular inspections would help with both awareness and compliance," Mr O'Brien Hartcher said.
"[And] more staff for the Swimming Pool Safety Authority to allow more frequent and more regular inspections."
The court heard that despite there being about 20,000 pools in the Northern Territory, the Swimming Pool Safety Authority was only able to conduct about 1,000 inspections each year.
The coroner also heard increased penalties and on-the-spot fines could encourage pool safety compliance.
"Compliance mitigates risk and mitigating risks saves children's lives," Mr O'Brien Hartcher said.
The coroner heard Northern Territory pool safety regulations did not currently require pool barriers to meet the Australian standard, with Mr O'Brien Hartcher telling the court legislation should be updated to "appropriately mitigate the risks".
Representing the Swimming Pool Safety Authority, Taylah Cramp told the inquest conducting annual inspections of each pool in the Northern Territory would be "more onerous" than the work done in other jurisdictions, which saw two, four or five-yearly inspections of swimming pools.
Ms Cramp said compliant pool barriers were important and the Swimming Pool Safety Act encouraged "personal responsibility" for home owners.
"It's interesting, though, that it takes between two and three inspections [to reach compliance]," Judge Armitage said.
"Which suggests it's very difficult for home owners to carry that responsibility without inspections from the authority."
Judge Armitage offered several "commonsense" pool-safety suggestions, including that if an adult became overwhelmed with supervision responsibilities they could "just call out, 'There's too many kids for me to supervise, can someone help'".
"This isn't about blaming anybody, but it is looking at our agencies and rules and regulations that govern our society to determine whether or not … there are ways we can mitigate risk for young children," Judge Armitage said.
"And to consider how we might go about making those appropriate changes so that children like Baby Croker can enjoy pools and parties but can do so safely with all the appropriate measures in place."
Near drownings missing in data
Mr O'Brien Hartcher also recommended that "all data on fatal and non-fatal pool drownings" be shared between the relevant authorities to facilitate investigations into swimming pool safety compliance.
The court heard that for every drowning in the Northern Territory, there were estimated to be eight near drownings in children under the age of four.
"Incidents of non-fatal drownings can also help us understand whether safety measures are sufficient and adequate," Mr O'Brien Hartcher told the inquest on Tuesday.
"However, they can only be informative if data is collected, and those incidents are reported."
Counsel for the NT Health Department, Casimir Zichy-Woinarski, told the coroner there were "complexities" in reporting such data.
He suggested the recommendation about near drownings should instead focus on incidents that were reported to emergency departments, as opposed to "all" instances of near drownings.
The coroner will hand down her findings and recommendations from the death of Baby Croker at a later date.
