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The Northern Territory Coroner has found "significant failings" contributed to the drowning death of a toddler in a remote public pool 530 kilometres from Alice Springs while he was under the supervision of a daycare service in 2020.

The five-day Coronial inquest held earlier this month heard that the death of Kumanjayi Jurrah occurred on 2nd December 2020 - in the remote desert community of Kintore - after three childcare workers took six children on their weekly excursion to the Kintore Swimming Pool.

Evidence presented to the inquest advised that on the day six children and two educators, Rebecca Pollard and Noretta Nolan, walked the short distance from the MacDonnell Regional Council-operated daycare to Kintore Swimming Pool while Team leader Paula Nadas followed behind.

The group was let in by lifeguard Paul Rigney, then got changed, grabbed balls to play with and headed to the round shallow children's pool, metres away from a 25m lap pool.
About 30 minutes later, Nadas signalled it was time to leave.

Council assisting the Coroner, Paul Morgan, told the inquest that Kumanjayi was last seen getting changed and the childcare workers left the pool without him.

Shortly afterwards, Jurrah's aunt saw the group walking back to the daycare and noticed her nephew was missing.

She sounded the alarm and within seconds council staff and community members began to search for Kumanjayi.

They quickly discovered none of the council keys, including the master key, could open the pool gate.

The Court heard the locks had recently been changed and the lifeguard, who couldn't be found, was the only one with access.

As the seconds ticked by, community members scaled the high barbed wire fence, ripping their clothes and skin to get over.

They then found Kumanjayi "floating face up in the part of the adult pool near the built in tiled steps".

Sitting with an Indigenous translator who relayed questions in Pintupi and Luritja, childcare workers Nolan and Pollard were both granted protection from incrimination.

Asked by Coroner Elisabeth Armitage "do you know how Kumanjayi got left behind that day?", Pollard responded "I don't know."

Nolan told the inquest she remembered watching Kumanjayi playing with a ball in the children's pool and recalled seeing him line up with the other children in the change area at the end of the swim session.

Nolan told the inquest that she'd worked at the daycare for a number of years but had received minimal formal training.

She noted that it was Nolan's "job to count the children" as they left the swimming pool.

In an emotional disclosure to the inquest Nadas conceded she was distracted and didn't count the children as they exited.

In February 2023, Nadas was charged with manslaughter, but earlier this year those charges were dropped.

She said she considered herself the "responsible person under the legislation" and had been left distraught.

She explained "I just don't know what happened."

The Coroner also heard that the lifeguard in charge of the pool was the last to leave and did not do a final sweep of the area.

He then locked the gate and took the only key, trapping Kumanjayi inside.

He had been summoned to the inquest but has not been able to be located by police.

The inquest heard there had been a series of systemic failings at the Macdonnell Regional Council leading up to Kumanjayi's death.

There was no evidence of parental consent for excursions nor risk assessments to ensure the safety of kids during them, and staff training wasn't provided in language.

Royal Life Saving Society - Australia data shows the Northern Territory has the highest rate of drowning deaths in the nation.

In addition, past research has shown that people living in disadvantaged parts of Australia are 71% more likely to drown than those living in areas of affluence.

Both the Kintore Swimming Pool and Kintore Child Care Centre have been closed since the incident.

Image: The Kintore Swimming Pool. Credit: NT Courts.

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