THE drowning deaths of three people at Forrest Caves on Phillip Island on Wednesday, January 24 this year and the subsequent death of another member of their family group the following day, has been investigated by the Coroner Sarah Gebert.
In a decision handed down on December 9, Ms Gebert found that three of the four, all of Indian origin and recently arrived in Australia, were unable to swim, and one, Jagjeet Singh Anand, aged 23 years, had limited swimming ability but no formal training.
While delivering her findings into the tragic incident, the Coroner made an appeal to the community ahead of the summer beach season.
“In the lead up to the summer season, I implore the Victorian community and visitors to our state to be aware of the risks of Australian beaches and take precaution where needed.”
Describing the circumstances of the deaths at Phillip Island on January 24, Ms Gebert said the deceased; Reema Sondhi 42 years, Jagjeet Singh Anand 23 years, Kirti Bedi 20 years, and Suhani Anand 20 years, were on a day trip to Phillip Island in a family group of nine people, including two young children.
They visited the Phillip Island Chocolate Factory and the National Vietnam Veterans Museum on their way to see the Penguin Parade but stopped off at Forrest Caves Beach to eat their lunch after seeing a sign by the road.
Interviewed later by police, three of the surviving family members said they did not notice any warning signs about the beach or the lack of Life Saving Victoria patrols on their walk from the Forrest Caves carpark to the beach.
After eating their lunch, adult members of the group joined the children who had been playing on the waters’ edge, but as they weren’t planning to swim on the day, all were fully clothed or mostly clothed.
However, at the point of deciding to leave the water and the beach to continue their journey, a large wave knocked some members of the group off their feet, leaving five struggling in the water, including the husband of one of the deceased, Sanjeev Sondhi, who managed to get to the shore.
Members of the group called for help and beachgoers retrieved three unconscious females from the water but were unable to revive them.
They were unable to find the fourth member of the group, Jagjeet Singh Anand “due to the rip and dangerous conditions”. He was located by the police airwing and a boat crew from Cape Woolamai Surf Lifesaving Club, in knee-deep water, 25 minutes after the alarm was raised at 3.30pm.
CPR and Advance Life Support Resuscitation was performed for an extended period on the beach on the four unconscious adults by paramedics and additional members from Victoria Police and the Woolamai LSC. After approximately 45 minutes of treatment with no signs of life, paramedics declared Reema, Jagjeet, and Kirti deceased. Suhani was flown to Alfred Hospital, arriving at approximately 5.52pm, however, after treatment and assessment she died in the Intensive Care Unit the following morning.
In establishing the contributing factors, the Coroner relied on the investigation of the incident by Sergeant Leigh Cole, who had been assigned as the Coroner’s Investigator. He outlined the following factors:
(a) While there was signage in place warning of the dangers of swimming at Forrest Bluff West, the family group did not notice, pay attention to, or think relevant any signs at the commencement of the walking track to Forrest Bluff West that warned that the beach was unpatrolled and had dangerous currents;
(b) Given that no one in the group had any swimming attire, they did not have an intention on entering the water but subsequently did so fully or mostly clothed;
(c) Each of the deceased had no or limited swimming ability and had little or no experience in ocean swimming;
(d) The group appears to have entered the water where a rip was occurring;
(e) It is likely the group believed this was a good place to swim as the water appeared calm;
(f) The group were subsequently dragged out into the rip; and
(g) They did not have the knowledge, skills, nor experience to navigate their way back to the beach.
He also referred to suggested recommendations made by Detective Acting Sergeant Madeleine McDonald, Coroner’s Investigator for a drowning death at Rosebud, which he considered were relevant to his investigation:
(a) Develop adequate signage including a multilingual format (the deceased in that matter had English as their second language). This was also a coronial recommendation made by then Deputy State Coroner Caitlin English in regard to the deaths of Ross and Andrew Powell; and
(b) Education and promotion of Surf Life Saving Australia’s ‘BeachSafe’ application (app) via social and mainstream media to encourage members of the public to check and use the information provided before attending the beach.
As part of her investigation, Ms Gebert also asked the Coroners Prevention Unit (CPU) to compile statistics on unintentional deaths at beaches along the Victorian coastline between July 1, 2014 and October 28, 2024.
“The CPU identified 75 unintentional coastline drowning deaths of swimmers during that period, with 36 of the deceased born overseas, 12 of unknown origin and 27 born in Australia.
“The statistics outlined above highlight the particular vulnerability of persons born overseas to accidental drowning in Victorian (and Australian) coastal waters. Life Saving Victoria estimates that 36 per cent of drowning deaths from 2012-13 to 2021-22 were of people born overseas. Eighty-two per cent of the fatal drownings involving people from Culturally and Linguistically Diverse (CALD) Communities resided in major cities, and the mean length of time living in Australia was surprisingly 20 years. The most common activities prior to drowning incidents were swimming, paddling or wading (31 per cent), walking or recreating near water (18 per cent), and fishing (17 per cent),” said Ms Gebert.
“Persons born overseas who visit or reside in Australia are unlikely to be familiar with the risks posed by beaches nor how to respond – education we often repeatedly receive as children as part of our early childhood education.”
She said there was no one easy solution to prevent ongoing fatal drownings but noted that education about water awareness and safety was paramount.
“It appears that in many cases, including this coronial investigation, clear signage warning of risks alone is inadequate.”
Ms Gebert noted that the efforts of Life Saving Victoria working with migrants and new arrivals, and the Multicultural Engagement Network’s work with the cross-council water safety group, were both evidence that the particular drowning risks faced by CALD communities in Victoria are understood and that concerted efforts are underway to address these risks.
She also recommended the BeachSafe app as a simple and easy to read resource for beachgoers to help them make educated decisions about safe places swim.
“Information on the Beachsafe app is also available in multiple languages. I support the ongoing work in this area and, in the lead up to the summer season, I implore the Victorian community and visitors to our state to be aware of the risks of Australian beaches and take precaution where needed.”
Mention was also made of the Bass Coast Shire Coastal Risk Assessment project, which was developed as part of the Surf Life Saving Australia Beach Drowning Black Spot Reduction Program in 2019, identifying hazardous local beaches and action to be taken.
The Coroner noted the findings of that report including “implementing a process for continuous monitoring and review of hazards” and also that while Royal Life Saving Australia indicated there is no immediate need to update recent signage, signs should be reviewed periodically as part of ongoing continual improvement safety practices.
The inquest also heard from the Bass Coast Shire Council’s Acting Coordinator Community Resilience, Nick Grant-Collins, who advised that the Multicultural Engagement Network was initially established to support public health messaging through Culturally and Linguistically Diverse (CALD) Communities Task Force funding.
“Specifically with respect to drownings, and following the drownings that are the subject of this investigation, Bass Coast Shire and Mornington Peninsula Shire convened a group of southeast Melbourne councils committed to collaboration and innovation to drive better beach safety outcomes for all community members, with a strong emphasis on engagement with CALD communities,” according to the report from the Coroner, recognising that most of the beach visitors come from the south-eastern suburbs.
“Further, in partnership with local land managers and Life Saving Victoria, Bass Coast Council is scoping improvements to emergency markers, as well as implementation of signage audits and new secondary hazard signage at high-risk beaches.”
Finally, the Coroner conveyed her sincere condolences to the affected families for their loss which tragically occurred in the setting of a joyful family day where no one could have imagined the devastating outcome.
She commended the actions of the other beachgoers and responding emergency services personnel who retrieved the deceased from the water and commenced heroic resuscitation efforts.