This study examined the incidence and circumstances associated with child drowning in public pools in Australia; and identified the frequency and nature of coroners’ recommendations. Retrospective case-series analysis of child (aged 0-10 years) unintentional drowning deaths in public pools were conducted based on Coronial data. A total of 12 child drownings were identified. A lack of supervision was recognized as the key contributing factor in 92% of cases, with the caregiver responsible for multiple children (83%); older children supervising younger children (17%); and a busy pool environment (25%) consistently linked with in-adequate supervision. To address drownings in public pools it is essential that coroner recommendations reach 1) aquatic centres so they can improve their practices; and 2) aquatic stakeholders so that strategies can be developed. Strategies that highlight techniques to assist caregivers responsible for multiple children and how best to provide supervision in a busy pool environment should be a focus.