About the Investigation

The Ombudsman commenced the review of certain child deaths on 30 June 2009 following the passage of the Parliamentary Commissioner Amendment Act 2009. The Department of Communities (Communities) receives information from the Coroner on reportable deaths of children and notifies the Ombudsman of these deaths. In accordance with the Ombudsman’s child death review function, children are defined as those under 18 years of age.

Through the review of the circumstances in which, and why, child deaths occurred, the Ombudsman identified a pattern of cases in which children appeared to have died by drowning. The Ombudsman decided to undertake an investigation into these deaths with a view to determining whether it may be appropriate to make recommendations to any local government or state government department or authority about ways to prevent or reduce deaths of children by drowning (the Investigation).