Publicly available rescue equipment might have prevented four drowning deaths, including the tragedy of a father who died trying in vain to save his daughter, a coroner has found.
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But coroner Paula Russell has not recommended such equipment be installed beside rivers, noting the ACT government's fears it would be vandalised, interfered with, stolen or misused.
On Monday, the ACT Coroner's Court published Ms Russell's findings on the deaths of Najeebullah Rafee, William Spencer Hooley, Meredith Nancy Hooley and Dinh Ta Nguyen.
Those people died after drowning in ACT waterways within a 16-month period.
Mr Rafee, known to his friends as "Najeeb", was a 23-year-old refugee from Afghanistan.
The Australian National University student, described as "a young man of significant promise", went to the Cotter Bend with members of his family in October 2020.
Unable to swim, he tried to use a board as a flotation device but got into difficulty.
Ms Russell found he had most likely lost control of the board in deep water.
He was underwater for an estimated 20 to 25 minutes before he was pulled out and raced to Canberra Hospital, where he died after 10 days in the intensive care unit.
Mr Hooley, a 48-year-old man known by his middle name of Spencer, was a successful trademarks examiner with IP Australia.
In December 2020, he took daughters Meredith, 11, and Morgan, 13, to Tharwa Sandwash on the banks of the Murrumbidgee River.
When Meredith began struggling in deep water, her father raced in to help her but she was seen flailing and pushing him underwater.
Morgan ran to a car park to get help, but it did not arrive in time to save her father or sister.
Mr Nguyen, a Vietnamese visitor to Australia, went fishing at Kambah Pool, on the Murrumbidgee River, in January 2022.
The 75-year-old's fishing rod slid into the water and he went in to retrieve it, only to be caught in a current.
About three hours later, police divers found his body submerged in water about 25 metres away.
In her findings, Ms Russell said there was no basis upon which to criticise the warning signage at each of the three locations.
However, she said it was difficult to assess the effect the signs might have on people.
In each of these cases, the coroner found those who had died lacked an understanding of the dangers the waterways posed.
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A matter of public safety therefore arose, with Ms Russell identifying a need for enhanced education and awareness programs.
She said these should be aimed at the general community and at specific groups, including culturally and linguistically diverse communities who might be less familiar with the risks associated with rivers.
The coroner accordingly recommended that the relevant ACT government agencies develop such programs.
While she did not recommend the installation of rescue equipment, such as life rings or throw ropes, Ms Russell said the government should consult with the Royal Life Saving Society of Australia about whether it would be feasible to place any at popular riverside spots.
Ms Russell said this could include consideration of "smart technology hubs", which the family of the deceased father and daughter had suggested.
Such hubs would integrate CCTV, microphone capabilities and artificial intelligence.
The coroner ultimately extended her condolences to the families and friends of all four drowning victims.
"The loss of these four lives has been immeasurable," she said.
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