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A Coronial inquest into the accidental drowning death of an Indigenous child at the Kintore Swimming Pool in the Northern Territory n 2020 has identified "astonishing", "disturbing" and "inexcusable" failures by the MacDonnell Regional Council (MRC).

21 month old Kumanjayi Jurrah was found floating in the adult pool inside the community's council-run facility after being accidentally locked inside alone.

He could not be revived.

In findings released on Saturday 16th November, Northern Territory Coroner Elisabeth Armitage said the toddler was one of a group of six children on an excursion to the pool from the Kintore Early Learning Centre on the day.

As the group was leaving the pool, Coroner Armitage said team leader Paula Nadas did "a scan of the area and located all six children" before becoming distracted.

Nadas would later admit in her evidence that she "didn't count them out the gate because they started going without me and we were running to catch up".

The inquest heard that moments later, lifeguard Paul Rigney locked the pool's external gate and drove home without doing "a final sweep (visual check) of the pools or their surrounds".

Shortly after that, Kumanjayi's aunt, Marina Jurrah, called out to Nadas asking where the boy was and the team leader ran back to the pool.

However, none of the available keys fitted the lock and with Rigney not able to be located, community members were unable to force open either of two gates.

Two men eventually managed to scale the barbed wire fence to get to Kumanjayi, ripping their clothing and skin in the process but it was too late.

Commenting on this, the Coroner advised “every second of frantic delay contributed to the likelihood of a tragic outcome.”

The Coroner found there was no documented risk assessment or risk management plan in place for the excursion or parent/guardian authorisations for any of the children, noting “it is inexcusable that fundamental steps such as conducting the supervision risk assessment were not actioned before Kumanjayi’s passing.”

Armitage said if, as it appeared, the council had reinstalled a fence at the pool without consulting with Royal Life Saving Society - Australia, "then that is astonishing and disturbing and demonstrates a continuing lack of understanding by MRC as to how to safely manage remote pool assets".

The inquest heard Nadas "blamed herself for this tragedy", telling Northern Territory Police shortly after the drowning "it's my fault 'cause I didn't double check afterwards" and "I'm responsible for all the kids so I'm responsible for this".

Coroner Armitage said Nadas had "made appropriate concessions, including that the supervision on the walk to the pool was inadequate" during her evidence, which she accepted as truthful and honest.

Armitage noted in her findings that while Nadas had only arrived in the community as team leader a week before the incident, "this excursion had been occurring every Wednesday for some time", advising “(this means) that the lack of a risk assessment, consent forms and training of educators can be understood as a systemic issue, rather than a failing of any one person.

"As this case has tragically proven, a reliance on common sense and the work ethic of the care workers was insufficient to mitigate the risk posed by this excursion."

Immunity from Prosecution for Council Workers
Nadas was charged with manslaughter in February 2023 but the charge was dropped earlier this year due to a broad immunity from prosecution for council workers under the Local Government Act.

Armitage recommended Northern Territory Attorney-General Marie-Clare Boothby refer the question of possible reform of the provision to the Northern Territory Law Reform Committee.

She stated “but despite any failings which might be attributed to the coordinator/team leader on the day, one must not lose sight of the fact that this excursion was occurring regularly, including prior to the coordinator/team leader's arrival in Kintore.

"Since the regular excursion started, there was no objective evidence that there was ever a documented risk management plan for this obviously high-risk activity.

"Without such a plan to mitigate the risk, the risk of such a tragedy occurring was always going to be high."

The Coroner said the immunity was "an anomaly" unique to the Northern Territory which appeared to have "no good policy reason" as its basis.

Advising that said she would consider the recommendation before making any further comment, Attorney-General Boothby stated "I acknowledge the findings and recommendations of the coronial inquest and I will take the necessary time to review and consider recommendation seven.”

A way forward
Coroner Armitage said she was "alarmed" to learn neither the pool nor childcare centre in the remote community, 530 kilometres from Alice Springs, had reopened since the tragedy, saying the question of whether such excursions should happen in future would be guided by further risk assessments.

The coroner said Kumanjayi's death had had "a devastating and ongoing impact in Kintore and beyond" with the community still divided as to whether either facility should ever reopen.

She added "the picture was one of fractured relationships, compounding the grief and suffering resulting from Kumanjayi's passing.

"As a result, I have also made recommendations relating to processes for mediation/restorative justice targeted at the difficult task of rebuilding relationships and determining a way forward."

Armitage said it was clear the healing process "had been grossly neglected and was long overdue" but welcomed efforts by the council and federal government "to progress a mediation/restorative justice process in Kintore".

Lifeguard Paul Rigney did not appear at the inquest with Northern Territory Police efforts to locate him having proved unsuccessful.

Image: Kumanjayi Jurrah was found floating in the adult pool at Kintore on 2nd December 2020, and could not be revived. (Credit: NT Courts).

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