Preventing river drowning deaths: Lessons from coronial recommendations

Issue addressed Coronial data provide rich information on drowning causal factors. Coroners may make recommendations to prevent future drowning events. Rivers are the leading drowning location in Australia. This study examines coronial recommendations associated with unintentional fatal drowning in Australian rivers from an injury prevention perspective. Methods All river drowning cases in Australia between 1 July 2002 and 30 June 2012 were extracted from the National Coronial Information System ( NCIS ). Recommendations were thematically analysed. Using a deductive process, each unique recommendation was coded to a category aligned to the Hierarchy of Control's 6 levels. An inductive process was used for those not categorised. Recommendations were also coded against a modified SMART principle. Results Of the 730 river drownings, 58 cases (7.9%) resulted in 71 unique recommendations. Victorian cases (X 2  = 32.1; P  < 0.01) and multiple fatality events (X 2  = 41.9; P  < 0.01) were more likely to have recommendations. Common categories of recommendations were administrative (39.4%) and signage‐related (18.3%). Recommendations were often low on the Hierarchy; namely administrative (67.6%) and behaviour (19.1%). Half (50.7%) satisfied four of six modified SMART principle components. Conclusion Coronial recommendations associated with river drowning in Australia are reasonably rare. Recommendations provide opportunities for organisations to enact change, however, they could be strengthened with a specified time period and higher order control strategies recommended. So what? SMART coronial recommendations may be more successful in achieving the behavioural, social and societal change required to prevent future river drownings. The recommendations examined in this study can be used as a benchmark for what could be considered appropriate safety actions.