An inquest has examined the death of two-year-old Kumanjayi Fly, who on March 29, 2023, fell into a septic tank in the backyard of his family's public housing home in the remote Northern Territory community of Watiyawanu.
His family did not know the cover and access point to the septic tank was neither safe nor secure, NT Coroner Elisabeth Armitage said in her just-released findings.
He died at the Women's and Children's Hospital in Adelaide on April 3, 2023 from his injuries.
The coroner found that relevant government departments , including housing and health, knew the septic system was failing, with numerous experts recommending it be upgraded or replaced.
Similar concerns had been raised in other remote communities where it was a potentially very expensive problem to upgrade or replace failing septic systems, her report said.
"Instead of addressing this widespread safety issue, the relevant government departments sat on their hands and did, effectively, nothing."
Had action been taken the septic system should have been upgraded or replaced and this tragedy would likely have been avoided, Judge Armitage said.
"Every child in public housing across our remote communities should be able to play safely in their own backyard without the risk of falling through a degraded access cover into a septic tank."
Urgent action was required to make public housing septic systems safe, the coroner said in her 46-page report.
It detailed how the toddler was playing with family nearby when he disappeared, only to be found when a relative noticed the tank cover was loose.
A neighbour reached in to find the boy was upside down in the tank and pulled him out of the sewage.
Audits undertaken after the toddler's death recorded more than 900 septic tanks at NT public housing homes alone.
The septic tank that Kumanjayi fell into had a corroded cover that meant it did not seat properly but that should have been detected and rectified before the cover failed, the coroner found.
"A dysfunctional repairs and maintenance system not only has the potential to breach statutory obligations of habitability, health and safety, it creates real risks to the health and safety of residents that can have fatal consequences," Judge Armitage said.
She recommended a timely progression to planned regular maintenance for remote public housing septic systems, with funding levels reviewed to meet the needs of such recurring maintenance.
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