The South Australian Coroner says a system of regular swimming pool safety inspections may be needed following the death of a one-year-old baby at his family home three years ago.
Bryce Ashton Eddleston drowned after he fell into the unfenced pool at his family home at Salisbury Heights in Adelaide's north in January 2010.
The baby had crawled through concertina doors left open while the family had dinner.
His father found him floating face down 10 minutes later.
The incident was captured on a home security camera which was shown to the Coroners Court during the inquest.
Coroner Mark Johns said the baby's death was preventable and would not have occurred had the home and pool been built in accordance with construction plans.
The inquest heard the couple's eldest child, who was nine at the time, had told his family to shut the door because he did not want Bryce to get out to the pool.
"It is clear that Bryce exited the house through the open bi-fold doors which were self-evidently not of a self-closing design," he said.
"As a result he was able to access the edge of the swimming pool and was attracted to the water in the way that so many children tragically are.
"I can only conclude that Bryce was not seen by anyone when he made his way from the kitchen meals area through the entertainment area outside to the swimming pool."
The inquest heard the baby's father, Anthony Eddleston, built the house and pool but did not install a child-proof fence despite laws requiring one.
Mr Johns said the Tea Tree Gully Council did not carry out an inspection after the pool was filled to make sure it was fenced.
"The fact remains that had the Council inspected the pool after it was filled with water, the inspection would have revealed that there had been two significant departures from the plans as approved by Council," he said.
"As the owner/builder, Mr Eddleston must take responsibility for this departure."
Mr Johns urged the State Government to consider introducing regular safety checks to ensure building codes are complied with.
"I have considered whether I should make a recommendation that every swimming pool should be inspected upon completion by the relevant planning authority," he said.
"However, there would be nothing to prevent a departure from the plans as depicted on the planning approval after such an inspection.
"It thus becomes necessary to consider a regime in which there is a regular inspection for compliance."
Mr Johns said swimming pool inspections are carried out in Western Australia every four years.
"Whether that is frequently enough to discourage an owner from making alterations in the intervening period to enable straightforward access from an alfresco area such as the Eddleston's enjoyed to a swimming pool without the inconvenience of a safety barrier is a moot question," he said.
Mr Johns recommended Planning Minister John Rau consider the facts of the case to make a decision on whether changes to regulations are necessary.