Background Major reductions in child drowning mortality rates have been observed historically in Victoria, Australia, for the period 1863–2000. Despite this trend, drowning remains the leading cause of unintentional child death in Victoria. This study investigates the residual fatal drowning problem in the Victorian child population (0–14 years) for the period 2001–2016.

Aims Describe the epidemiology of child drowning deaths in the Victorian population in 2001–2016; investigate risk factors and direct antecedents to these deaths.

Methods Population-based retrospective case data were extracted from the National Coronial Information System for 16 years (January 2001–December 2016), and case-by-case analysis was conducted. Associated factors were determined using univariate and Poisson analyses.

Results 88 of 97 cases had information available for analysis, pools were the most frequent location (30%); 70% of all cases occurred between 08:00 and 17:00; most victims were not deliberately in the body of the water (73%), for example, the pool. Supervision lapses included carers leaving the room when the child was in the bath (16/18), siblings left to supervise the child in private pools (7/23), inadequate pool fences (8/23) or faulty/open gates (4/23), or neighbours’ pool spa (4/23). Delays in finding the child occurred when searches occurred elsewhere, before the body of water (21/88) and when carers were asleep (5/88). Fourteen of the 88 children had an intellectual disability or predisposing medical condition. The grouped Poisson analysis demonstrated that age 0–4 years, male gender and rural place of residence were significant. A downward trend in drowning rate continued in this period.

Discussion and conclusions A case-by-case analysis of a drowned population of children identified details of risk factors and antecedents not previously described. Missing data on antecedents were common, likely resulting in undercounting. Further enhancements to systematic data collection are needed. The results support a systems approach to drowning prevention.