• Eight children drowned in the 2021-2022 summer, with incidents in rivers, pools, and lakes.
• Coroner Michael Robb has released a report highlighting the need for close supervision of children near water.
• He recommends banning small pools under 1.2m and improving water safety signage and education.

Eight children who drowned over one summer have been the focus of a recent coroner’s report that has highlighted the need for close supervision when children are near water.

The eight deaths occurred in the summer of 2021-2022 around the country including two in Northland, two in Wellington, Napier, Minginui, Christchurch and Auckland.

“In consideration of the level of commonality in the age of these children that drowned, and some similarity in the circumstances of those drownings, I make general comments and recommendations with the hope that, if brought to the public attention, this may reduce the risk of similar deaths occurring in the similar circumstances in the future,” Coroner Michael Robb said in his report released to the public today.

Four of the children were 5 years old, three were toddlers and the youngest was just 9 months old, which Coroner Robb noted all were an example of how things can go wrong quickly when adult supervision is not designated.

“Supervision around water is only effective when it is accompanied by either direct physical contact with the child, holding the child, or holding their hand, or being so close that the moment a child comes into contact with the water the child can be physically reached,” he said.

The deaths occurred across lakes, beaches, pools brought off the shelf in department stores and one at a public swimming pool.

Coroner Robb highlighted how children can slip below the surface of water quickly, without drowning, splashing loudly or any other overt action.

“Supervision that is at a distance and while carrying out other tasks will, as a matter of practical reality, be intermittent observation rather than constant observation.”

The report also highlighted the need for detailed signage at public swimming pools that was blunt, clear and consistent nationally.

Two of the deaths occurred in temporary pools which the coroner was critical of around non-consistent safety guidelines and recommended any under 1.2m be discontinued from sale.

“I understand that the short answer from the helpful advice from MBIE is that it would be a complicated process to ban small temporary pools from sale. However, from a Coroners Court perspective, despite being difficult I maintain my recommendation for the banning of those pools in order to prevent avoidable deaths of young children.”

The coroner said any pools 1.2m or higher should not be sold without an appropriate safety gated entry.

Coroner Robb has recommended that temporary pools 1.2m or higher in height be sold only with an appropriate safety gated entry. Photo / Coroner report

Coroner Robb acknowledged funding for swimming programmes posed significant issues and called on councils to strategically invest in targeted programmes for high-risk populations.

“I recommend a proactive approach be taken by councils be it working with Water Safety New Zealand, or otherwise, to ensure and/or promote provision of water safety classes in their communities and consistent messaging that water safety is essential knowledge for those with young children.”

The coroner emphasised that without better investment and funding, many children, especially those from low-income backgrounds, will continue to lack basic water safety skills, increasing the risk of drownings​.

Coroner Robb expressed his condolences to all the families grieving as a result of their child’s death.

Birthday camping near a stream

A 2-year-old was with his family at a camping site January 8, 2022 in Northland celebrating a birthday near a stream.

For most of the day the children were under general supervision playing in the water but at some point the toddler wandered back to the swimming hole without supervision.

An extensive search was carried out for about an hour before he was found submerged in a deeper part of the swimming hole.

The coroner found there had been a false sense of security created by the multiple adults and teenagers present and recommended adults must be in the water with young children at close range and uninterrupted.

He also highlighted the shallow but unpredictable nature of streams and strong public messaging emphasising what proper supervision entails.

Above-ground pool

A 19-month-old toddler died in Middlemore Hospital in 2022 after he was found floating face down in an above-ground inflatable swimming pool the Auckland family had been given for Christmas.

The 1.2m pool required a ladder to climb into it and the family had a rule it was to be removed from the pool after each swim and when no adults were around.

The coroner said he was “a strong toddler who was capable of climbing stairs and ladders” who had enjoyed swimming with arm and body flotation devices and under the supervision of adults who were in the pool with him.

On January 12 he had been swimming with his father but after being showered and dressed he made his way back outside to the pool without anyone noticing.

He was found in the water by a teenage cousin, given CPR by his family and rushed to hospital, but was unable to be revived.

The pool did not require a building consent but a fence should have been in place and the coroner has recommended pools this height should not be sold without the appropriate gate fitted.

Paddling pool

An infant was just 9 months old when she was found having drowned in a paddling pool at her home Porirua in 2022.

The child’s mother, who was the sole adult at the property, had gone to sleep and placed the infant in a bassinet beside her on the floor.

However, when she woke up the infant wasn’t in the bassinet and had crawled outside to a paddling pool where her mother found her lying face-up, but unresponsive.

The coroner noted the child’s older sibling had left the property on a number of occasions unattended, opening internal and external doorways to get out, sometimes travelling several kilometres on foot and was critical that nothing had been done to stop them.

The baby was just nine months old when they found their way back to the paddling pool. Photo / 123RF

“All three children were mobile. Why [the child’s] mother did not wake when the children in the household began moving about the house, from the lounge, out the back door, and into the paddling pool, is unknown,” the coroner said.

“There was a paddling pool in the backyard that could be accessed by a mobile toddler in circumstances where through the actions of the (older child) or the door simply being left open there was nothing to stop [the infant] entering and drowning in the pool.”

The coroner said that the death could have been prevented with adequate supervision but the reality was that she was genuinely struggling to cope, and that state agencies like Oranga Tamariki should have identified this and intervened earlier.

Campsite waterhole

A 5-year-old boy drowned in January 2022 when he was with whānau at the Mangamate Waterfall Campsite Whirinaki River, near Miniginui, at a waterhole.

The young boy went missing and whānau searched the area around and in the river. The boy was found fully submerged about a kilometre downriver from the waterhole and campsite.

CPR was performed until emergency services arrived but he was unable to be revived.

Police officers found “the water level varied from ankle to waist height, that the rocks on the bottom of the river varied in size which made it very difficult to walk” and the rocks were slippery.

The river current flowed freely with no visible obstructions that would have stopped the boy until he reached the point he was found, near the bank.

The coroner noted the boy’s uncle said the boy had become cold and he’d seen him leave the water to go and eat. His mother remembered seeing the boy on the riverbank, but also recalled looking away for about five minutes.

Emergency services were called to the Mangamate Waterfall, on the Whirinaki River – inland from Minginui in Te Urewera.

The boy was described as being “scared of the water” and “not wanting to get splashed by others”.

The coroner said it was possible the boy had deliberately entered into the water or had been walking on rocks and slipped. Once in the water, the flow of the river would have made it difficult for him to regain his footing on the rocks.

The coroner recommended active supervision by a designated adult for that child, issuing a warning about the “false sense of security” where there are numerous adults or older teenagers in the area, in a general supervisory role over a group of children.

He said that in social settings, it was also easy to get distracted by conversations or using a mobile device, but constant visual observation means constant, rather than intermittent checking on a child’s location, and children aged 5 and younger needed to be in direct contact with, or within arm’s reach of, a supervising adult, as they can slip below the surface within seconds and drown unnoticed.

Kai Iwi Lakes

A family who was unfamiliar with lakes, travelled to Kai Iwi Lakes in Northland on January 4, 2022.

A 4-year-old was playing in the water, which has a significant drop-off in depth, with his sister who turned to retrieve a balloon. When she turned back, her brother had disappeared.

The boy appeared within minutes floating face down and was unable to be revived.

The coroner found the boy was unable to swim making him vulnerable if he lost his footing, there was limited signage around the drop-off and a brief lapse in supervision to be contributing factors.

The coroner noted the Kaipara District Council has since implemented improved signage but also recommended marker buoys be implemented to indicate deeper areas.

Public Pool

A 5-year-old girl was unsupervised when she made her way into the shallow end of a public swimming pool, slipped below the surface and drowned.

She was discovered floating face down at the Waltham Swimming Pool in Christchurch where the depth was 1.3 metres on December 22, 2021. While her grandparents were looking after her, she entered the main pool making her way from the very shallow entrance area into the deeper waters. An older sibling was also in the pool, but they were not swimming together.

There were lifeguards on duty who were actively watching the pool, which had about 50 people in it, but they had not detected the girl having difficulties.

The coroner has called on councils to invest in community access to water safety programmes. Photo / Kurt Bayer

The coroner said the girl’s grandparents did not appear to be aware of that requirement children 5 or younger needed to be in the water with someone aged over 16 who remained within touching distance of them.

While they were keeping a general observation on the children they were not within arm’s reach or aware of where she was when she got in trouble.

It was recommended that the signage at public swimming pools be prominently displayed and that the messaging be “blunt, clear and consistent nationally”.

“Signage and messaging that asks adults to ‘supervise your child’ are in my view well-meaning but unfortunately open to different interpretations. The messaging needs to explain what ‘active supervision’ means in a water safety sense.”

Marine Parade Beach

A five-year-old boy was swept from his mother’s hands on Napier’s dangerous Marine Parade beach on December 10, 2021. Several passers-by got into trouble in the waves trying to save the drowning boy, before four police officers entered the water.

Constable Ben Whitley reached the boy and brought him to shore but he could not be revived.

The coroner said the boy and his mother had been at the water’s edge, splashing in shallow water and playing in the small, breaking waves when they were both swept off their feet by an incoming wave which took them by surprise.

Marine Parade where a child tragically lost his life in 2021.Photo / Gary Hamilton-Irvine

He said the mother had “done everything right” in directly supervising her son and was in direct contact with him when the wave hit.

By the time she regained her footing, she was already in chest-deep water and the child was being taken further and further from the shore.

The coroner said he had no criticism of her actions that day.

“She was right there with him, providing direct support to him but was sadly unable to save him.” “This was an accident in a situation that was difficult to anticipate and took her completely by surprise.”

The coroner commended the members of the public and the police officers for their rescue attempts, which involved personal danger to them as well.

He listed other deaths from drowning at Marine Parade Beach and acknowledged the Napier City Council for its continuing work on water safety, and its efforts to provide effective warning signs.

There are 21 water safety signs along Marine Parade Beach.

Popular swimming hole

A five-year-old boy who had enjoyed an afternoon at a popular swimming hole was last seen throwing pebbles in the water.

But when whānau went to pack up they realised he was missing.

They started searching and eventually called emergency services who found the boy four hours later about 40m downstream, submerged in the water.

The boy, who was non-verbal and special needs, and his mother had gone with other whānau to a location known as the Maoribank swimming hole on the Hutt River near Ngati Tama Park on January 18, 2022.

The boy and his mother had not been to the area before but there were many people there as it was a popular swimming hole.

His mother said he was very active, always moving, and on that day, he was with another younger cousin when they walked through a gap in the rocks and were throwing pebbles and rocks into the river.

She said she could initially see them through the gap in the rocks. Eventually, the younger 4 cousins returned to the adults while the boy stayed next to the river.

At 5pm the decision was made to leave but his mother realised he was nowhere to be seen and the coroner said she was unsure how long he had been out of her sight.

Police were called and he was eventually located by search and rescue personnel in an area that was between 3.5 m and 4m deep.

“Police investigations identified (he) had likely entered the water in the area where he had last been observed by whānau and had then been swept by the river current down the river into the deeper waters of the waterhole.”

The coroner said children can slip below the surface in a matter of seconds and drowning can occur without any calling for help, loud splashing or other overt action.

“When groups of children are being generally supervised by a group of adults there is a risk that not every individual child is being watched at every moment. As drownings can occur in a matter of seconds constant and vigilant supervision is required of each individual child.”

Shannon Pitman is a Whangārei-based reporter for Open Justice covering courts in the Te Tai Tokerau region. She is of Ngāpuhi/ Ngāti Pūkenga descent and has worked in digital media for the past five years. She joined NZME in 2023.