Swimming Pool Drowning

[Legion]

This weekend there was a drowning in Dundee.

A seven year old was found under the pool covers.

This incident is still under investigation by Dundee Council and of course the HSE.

Read about it here.

http://news.bbc.co.uk/1/hi/scotland/tayside_and_central/7021688.stm

Latest story here.

http://www.dailyrecord.co.uk/news/scottish-news/2007/10/03/drowned-boy-s-mum-says-lifeguards-didn-t-care-86908-19886228/

[admin]

What a horrendous story. Was the child not supposed to be with an adult over the age of 18?

[Legion]

Not necessarily.

The guidelines for admissions policies are more for younger children.

Children under 4 should be accompanied by an adult on a one to one basis, and 4 to 7 year olds on a two to one basis although this policy may differ from pool to pool according to circumstances and demand.

Obviously many families have more than 2 children under the age of 4 or both parents cannot be present when the kids want to swim, so special mums and toddlers sessions may take place, restricted to shallow water with coaches and extra supervision by pool staff etc.

When admitting kids over 7 the managment act on risk assessment, taking into account the design features of the pool and other relevant safety related matters.

Some things to consider are the childs swimming ability, height in relation to pool depth, age and inexperience, lack of maturity and judgement, ability to read warning signs, and potential to become over exited.

I agree that it was a horrendous tradgedy especially as Luke's mother only took him because they met two friends who were going swimming.

The managment and HSE investigations are still going on and it will probably be some time before all the questions are answered.

[admin]

Our local pool has a rule that children under 8 must be with a parent and under 5's (I think) only 1 child per adult. It means I often have to go swimming with the small people in my family and their mums, Shame!

[ericp]

An horrendous accident, whether the lad would have survived if things had been done differently we will never know.
Whichever way you look at it though, the duty manager, pool side staff and those that covered the pool will have some uncomfortable questions to answer.

RIP

[Legion]

The case will almost certainly go to court.

If there is enough evidence the Lifeguards could be prosecuted for a breach of section 7 of the HSAWA in that they failed in their duty of care, causing death.

Pool Operators could be prosecuted individually, Directors, Managers, etc under Section 37 and the Organisation under Section 3.

However, the new Corporate Manslaughter and Corporate Homicide bill should go through Parliament before April 2008.

This law will make it easier to prosecute organisations without the need to identify individuals at fault, and could be applied in this case.

There is the possibility that there could be more than one prosecution in that Lifeguards, Managers, and the whole Organisation could all be charged.

Prosecutions of this type are thankfully rare and the figures for last year showed 28 prosecutions under sections 7 and 37 with average fines of £679 and £3,700 respectively, most of these were for relatively minor breaches.

One drowning especially of a child is too many, but we should be aware that swimming pool drownings only account for 2-3% of drownings in the UK with around 350 million pool users and statistically more people drown in the bath than in swimming pools.

[ericp]

Reading this reminded me of the incident in Wales when the child was saved as a result of the computer "thingy" called Poseidon. Having just looked up the site I was amazed there are only 5 of the devices in the UK.

http://www.poseidon-tech.com/us/pressRelease082005.html

[Legion]

Poseidon is an expensive system and only raises an alarm when it detects a body on the pool floor which has not moved for 15 seconds.

It is not a substitute for good Lifeguards and pool safety operating procedures.

I also believe the pool in question has a wave machine which may give problems with visibility under the surface and may mean it is unsuitable for Poseidon in that a body under the surface would still move around.

Poseidon tends to sell more systems on the continent where the tendency is not to utilise Lifeguards the way we do, or should, in the UK with constant supervision.

[admin]

But if the pool in Question (the one in Wales) may have problems due to the wave machine and it still saved a life they must surely be of benefit, even more so if there is no wave machine?

[Legion]

Sorry. I meant the pool in Dundee.

The pool in Wales was a conventional pool but 3.8 metres deep at the deep end.

These type of pools were popular with local authorities in the early 70s and were often designed with a wall of glass on one window side, this can cause the glare from the sun to make it very difficult to see under the surface at certain times of day depending on the Lifeguards position(s).

There is a category of victim known as a silent drowner, a swimmer who loses consciousness and just quietly sinks.

I think that some of these factors may have been involved in the Bangor incident as there was a significant time delay between the girl sinking and the Lifeguard entering the water.

Lifeguards are taught the 10/20 rule which means they scan the zone they are responsible for for 10 seconds and should be able to get to anyone requiring assistance in 20 seconds.

As more than 30 seconds elapsed before the Lifeguard intervened the inference is that the Lifeguard(s) did not see the girl sinking and were unaware she was in trouble until the alarm sounded.

Poseidon did save a life in this instance, but the girl should not have been able to disappear unnoticed by the pool staff.

As I said in a previous post the number of drownings in swimming pools is very low and good Lifeguards should be able to prevent them happening rather than rely on a machine to alert them when it may already be too late for the victim.

If the victim had been a sudden cardiac arrest who was not resuscitated successfully the headlines would not be saying Poseidon saved a life.

They would more likely be asking if Lifeguards need a machine to tell them they have a dead body in their pool.

[Anonymous]

A sad story. The mum must be devastated.

I wasn't aware of the Posiedon, it seems like a good piece of equipment that will save some live.

[Legion]

Yes, if it is instrumental in saving lives then I am all for it, but it should be remembered that Poseidon works well in some locations, and not so well in others.

There are a number of factors that determine how well the system works.

It seems to work best in conventional pools where the usage is structured and the pool has a deep end suitable for diving.

It doesn't work as well in busy shallow leisure pools and wave pools, as I mentioned. The reason for this is that Poseidon detects lack of motion.

[whiteminiman]

Poseidon is absolutely no substitute for good Lifeguards. I have several videos captured from the system that the company use to demonstrate the "success" of their system. To me, all those videos demonstrate is that the Lifeguards have failed to correctly implement the 10:20 system that Legion mentioned above.

In my mind, Poseidon only causes Lifeguards to be complacent, relying on the "third eye" to do the work for them. Having spoken with Lifeguards at the swimming pool at Oxford University - they hate the system, as it frequently false alarms, and doesn't particularly like working in a pool with a movable bottom.

For what it's worth, SwimTag has the same problems with it's implementation.

Regards,
WMM

[Legion]

The alarm will go off if somebody "plays dead" or just stops moving for a while.

That is all it does.

CCTV cameras on the lifeguards in some pools might be more effective.

[Legion]

This is the Judges summing up statement at the conclusion of the Trial.

I Have posted sections of it in the thread below on Corporate Homicide/Manslaughter but this is the full version for those who may be interested in the legalities.

There can be few greater tragedies in anyone’s life than death of a child. To have the suffer the loss of a child is contrary to the natural order and experience of life teaches us that any loss contrary to the natural order can be close to unbearable. To lose a child in circumstances where a large degree of systemic fault can be so readily identified by the Health and Safety Executive makes the loss all the more unbearable. Patently, no one wanted Luke Hutton to lose his life on 29th. September, 2007 and I have been made aware, that I do not need to be made aware, that many people have been badly affected by what took place and a number of employees of Dundee Leisure have required counselling. It is necessary, and it is a necessary part of the function which I am obliged to undertake, to attribute fault where fault falls to be attributed. That is the purpose of any prosecution, to determine guilt for the commission of a criminal offence. But in a case of this nature, what is of much greater importance to this court is that it be satisfied, in its role as guardian of the application of the law and given its responsibility for the welfare of children, that lessons have been learned from this experience and that action has been taken to prevent any recurrence. And not for the first time, it is important that I express public thanks for the very considerable efforts of the staff of the Health & Safety Executive for the detailed investigation they have undertaken and for the thoroughness and the quality of the information furnished by them to the Crown to help explain what went wrong, over and above the prompt and effective enforcement action they took in the immediate aftermath of this tragedy. I’m also grateful to the officers of Tayside Police in undertaking professionally what must have been a most difficult and sensitive enquiry, and to staff from the Scottish Ambulance Service and the medical and nursing staff at Ninewells Hospital who did all they could to ensure Luke was given every chance of survival Sadly, the reality is that he would have been beyond resuscitation within five minutes of his immersion in the pool.

Every child should have the right to participate in as many sporting activities as possible and learning to participate in sport should be a happy and rewarding experience and that applies to swimming as it applies to all other sports. Scotland has had over the last 50 years an extraordinary record in producing top class international competitors in all levels of swimming competitions. Every child should, as soon as possible, be given the opportunity to learn how to swim. That is why provisions such as those which exist at the Olympia and at other swimming pools throughout the country are important and should be supported. But for those who cannot swim, it must be appreciated that a pool of water that extends to a depth beyond which the non-swimmer can stand is a risky place. Every parent should understand that. Every parent has to accept responsibility for ensuring that their child is taught to swim in an environment in which that teaching can be carried out safely whether by them or by delegation to another responsible adult. Mrs. Hutton will no doubt regret for ever more the unfortunate chance meeting with the family on the bus who were going swimming and who persuaded Luke to come with them, as she had set out on the day to take him to the carnival. I have to say she must have known he could not swim and appears to have given little or no thought as to how he would be supervised when the only swimmer in the group in the pool was a 9 year old girl, who, as it turns out, was not a good swimmer and who had her own 8 year old brother to supervise. This 9 year old girl, who, unfortunately for legal reasons, cannot be identified comes out of this tragedy with a great deal of credit for it is clear from the information which the Crown has gathered that she went to great lengths to exercise what in her own young way she recognised as her responsibility to supervise the two non-swimmers. On more than one occasion she recognised that they were in difficulty and went to their assistance and, at the end of the session, she had got Luke at the edge of the wave pool, where he was safe, before she went to retrieve her younger brother. Unfortunately, Luke then found a playmat and could not resist trying this out in the wave channel, and it was his decision to do this, what should have been a bit of fun and a bit of adventure, that cost him his life.

I am informed that it was the 9 year old girl who bought the three child tickets for the swimming. The tickets were issued by the staff receptionist notwithstanding that the official policy was that no one under nine got admission without an adult to supervise them. It appears this policy was frequently honoured in the breach. I regard this as of huge significance to the present proceedings as this was the last clear point of control at which someone should have been saying to the child’s mother, “Can your son swim ? Who is going to supervise him in the pool ?” These questions were not asked and the situation was allowed to develop where a nine year old was admitted and had in her charge and eight year old and a seven year old neither of whom could swim. The individual who issued these tickets was at fault and those responsible for a system which allowed that to happen routinely as it did at the time are at fault.

One then has to ask what were the lifeguards doing. I do not think I have been told for how long the children were in the wave pool area but I get the impression that it must have been the best part of one and a half hours, by which time they would be beginning to tire, at least. As the end of the session approached, there were fewer people in the pool. One would have thought during a session of that length, particularly towards the end when the numbers of swimmers was reduced, that some lifeguard would have seen a small boy who could not swim in the wave pool. Lifeguards should have been asking the question, “Who is supervising this child ?” and deciding whether or not his continued presence there constituted a risk. They did not appear to be aware of his presence and did not recognise that he was at risk. This tells me that there was something wrong with their training.

There is obviously something patently wrong with a system of lifeguarding a swimming pool into which non-swimmers are allowed to enter in which there is a blind spot, in a potentially dangerous area. That was obvious to the health and safety inspectors. Why was it not obvious to the lifeguards and to their management ? Why was no risk assessment carried out prior to the tragedy by an independent agency or even someone with proper training in assessing risks to safety ? The creation of a blind spot and the failure to have a risk assessment or an independent agency assess safety are major failures on the part of Dundee Leisure for which its management are culpable and must take responsibility. To be fair to them, they have done so. The wave channel wall which created the conditions in which Luke drowned has been removed. There has been a full risk assessment and a safety co-ordinator has been appointed. Lifeguards have undergone a rigorous training regime and the points at which they are stationed have been revised so there is no longer a blind spot. Reception staff have been instructed about the proper admissions policy and no one under eight will now be admitted without supervision. With all due respect to the management of Dundee Leisure and those they have consulted I would be failing in my duty if I did not express concern about unsupervised eight year olds and would respectfully suggest that nine is more appropriate and even then questions should be being asked about their ability to swim. The present case demonstrates too tragically the error of assuming that eight year olds can look after themselves in a swimming pool. The playmat floats have been removed. There is a different system for checking that the pools are empty at the end of sessions. What has yet to be done is the replacing of the tiles which make it difficult to spot a white person under the water. That requires to be addressed promptly. So lessons have been learned and action has been taken, but I have to ask why Luke had to lose his life before this was done and before the failures were recognised. And I have to say to all parents you cannot assume that if your child cannot swim that he or she will be safe in a swimming pool and it is for you to organise appropriate supervision.

It is something of an irony that the vehicle used for this prosecution is the Health & Safety at Work etc Act, 1974, which was designed to protect people at work albeit as this case shows it also has provisions to protect people affected by those who do not carry out their work properly. Perhaps the legislature requires to have a further look at the whole question of safety at sporting venues and form a view whether legislation written plainly from the point of view of protection of the participating public, particularly children and others with limited ability, needs to be put in place.

The failures in this case on the part of Dundee Leisure are substantial and largely systemic. The function which I have to undertake is one of punishment and deterrence. Providers of leisure facilities must understand the need for proper risk assessment and the elimination so far as possible of all significant risks. They must ensure that proper admissions policies are in place and are enforced having regard to the residual level of risk. They must ensure that lifeguards or supervisors are properly trained and are in the right position. They must not create hidden dangers for the unwary. Had all these matters been properly attended to in the present case, the likelihood of this fatal accident would have been greatly reduced.

It is right and proper that this court should express its condolences to Luke’s mother, his sisters, other relatives and his friends. They could not help but be hugely affected by his untimely death. I have to impose a fine by way of punishment for the failures which contributed to his death. I am not engaged in any kind of process of evaluating Luke’s worth. That is not my function and that would be a crude and largely pointless exercise. I cannot ignore the reality that Dundee Leisure, being a company limited by guarantee owned by Dundee City Council, is not well off and just as I have to have regard to the means of an individual in working out what is an appropriate fine, I have to do the same with this adjunct of the local authority. I also have to take account of the timing of this plea and the level of co-operation with the police, the Health & Safety Executive and now the Crown in bringing the question of prosecution to a conclusion without the need for what would have been a highly emotive and distressing trial. The fine imposed has to reflect a significant degree of culpability but also the reality of Dundee Leisure’s financial position as the only people who will suffer from a swingeing financial penalty will be those who use the leisure facilities they operate and council taxpayers and that, in my opinion, standing the changes which have been made in reaction to Luke’s death, would be counter-productive. Had this matter gone to trial, in all the circumstances, I would have imposed a fine of £60,000. Instead, having regard to this early plea, the fine will be one of £40,000, recoverable by civil diligence.