Recurring concern

Inadequate controls for drowning risks in swimming pools

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First reported 23 May 2014•Latest report 18 Sep 2024

Definition

What this concern includes

Includes controls specifically dedicated to preventing, detecting or responding to drowning risks in swimming pools, including lifeguard or poolside supervision, CCTV coverage and monitoring, staff training and response guidance, patrols, rescue equipment and related pool-safety arrangements.

Not included

  • Excludes general pool maintenance, water quality, signage or operational deficiencies where drowning prevention, detection or response is not the shared unsafe condition.
  • Excludes generic staff training, staffing or communication deficiencies unless they directly impair a dedicated swimming-pool drowning control.
  • Excludes drowning risks in open water, beaches, watercraft, baths or other non-swimming-pool settings unless the assertion explicitly concerns the same swimming-pool control system.
  • Excludes failures occurring after a person has been safely detected and rescued, including subsequent medical treatment or investigation.
Reports
8

Distinct published reports

Individual concerns
19

A report can raise multiple concerns

Date range
2014–2024

First to latest report issue date

Stated actions
8

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

ABTA Ltd1
ACR Leisure Limited1
Atlantic Reach Limited1
DW Fitness First1
Institution of Occupational Safety and Health1
Royal Life Saving Society UK1
The Bannatyne Group Limited1
The Chartered Institute of Environmental Health1
The Dalmeny Hotel1
ukactive1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Cornwall and Isles of Scilly

    AI-generated summary

    Robin van Caliskan · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Robin van Caliskan, aged five, drowned in the main pool at Atlantic Reach holiday park on 31 July 2023 after being briefly unsupervised; resuscitation was unsuccessful. The principal concern was that the pool operated without lifeguards, despite being busy and close to maximum capacity, and an enforcement officer considered the company’s approach borderline and said more should be done.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide lifeguarding services in the pool except when large inflatables were permitted

    Wider context from the report

    “1) A risk assessment conducted by the company that took account of existing Health & Safety Guidance concluded that it was not reasonably practicable to use lifeguards except on the relatively few occasions when large inflatables were permitted in the pool. 2) While there was felt to be compliance with existing minimum legal standards, a Health & Safety enforcement officer with Cornwall Council felt this was borderline. She observed that similar sized companies elsewhere did provide a lifeguarding service. She felt lessons had not been learned and said that the company should be doing more. ”

    Source location

    Robin van Caliskan · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the swimming pool risk assessments in light of the inquest evidence and applicable HSG 179 guidance.

    Verbatim wording from the response

    “The Company confirms that it has reviewed its swimming pool risk assessments since the inquest and in light of the evidence that was heard. It has again had regard to HSG 179 and the requirement to ensure the safety of pool users so far as is reasonably practicable.”

    Source location

    Response from Atlantic Reach
    Page 4 · response
    Published 19 September 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Reconsider lifeguard provision during annual risk assessment reviews and when significant changes or other events indicate that review is required.

    Verbatim wording from the response

    “The Company has concluded that it is not reasonably practicable to provide lifeguard supervision at this time. This position will remain under constant review and will be reconsidered –”

    Source location

    Response from Atlantic Reach
    Page 5 · response
    Published 19 September 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing alternative control measures are considered sufficient because HSG 179 permits them where lifeguarding is not reasonably practicable.

    Verbatim wording from the response

    “The evidence was that the Company had adopted the guidance set out in HSE Guidance HSG 179, Health and Safety in Swimming Pools, and had concluded that the provision of lifeguards was not”

    Source location

    Response from Atlantic Reach
    Page 2 · response
    Published 19 September 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Providing lifeguard supervision is considered not reasonably practicable because qualified staff shortages, recruitment disruption, supervision risks and substantial costs constrain delivery.

    Verbatim wording from the response

    “The practicalities of providing lifeguards:”

    Source location

    Response from Atlantic Reach
    Page 5 · response
    Published 19 September 2024

    Open published response
  2. Inner North London

    AI-generated summary

    Catherine Mary GIBBON · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Catherine Mary Gibbon suffered a seizure while swimming at a gym on 1 June 2018 and remained face down in the water for around ten minutes. She sustained a hypoxic-ischaemic brain injury following non-fatal drowning and died. Concerns included inadequate pool monitoring and CCTV arrangements, a broken camera, insufficient staff training and emergency equipment, and gaps in first-aid certification systems.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to train and guide reception staff in CCTV monitoring

    Wider context from the report

    “3. The pool was not under continuous supervision and there was no legal requirement for a lifeguard, but it was under CCTV surveillance. The CCTV monitor was in reception. However, no training or guidance was given to the gym receptionist about what she should look for on the monitor and what she should do if all was not as she expected. Most especially, she was not given any instruction as to how frequently to check the monitor. ”

    Source location

    Catherine Mary GIBBON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to prevent first aid certificate lapses through a failsafe renewal system

    Wider context from the report

    “9. Fitness First had made the decision that all first aid certificates would be renewed after one year rather than the usual three, but then the certificates were allowed to lapse because one person made an error and there was no failsafe system. ”

    Source location

    Catherine Mary GIBBON · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  3. Inner North London

    AI-generated summary

    Kamal Yahyia AL-HIRSI · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kamal Yahyia AL-HIRSI, a cleaner at a London health club, suffered a cardiac arrhythmia and slipped beneath the water while cleaning the swimming pool on 10 October 2017. Resuscitation attempts were too late to change the outcome. Concerns included dangerous pool-cleaning practices, inadequate water-safety and defibrillator training, ineffective emergency alarms and communication, limited CCTV coverage, and procedures that remained substantially unchanged ten months after his death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    CCTV failing to provide visibility of the pool underwater and in blind spots

    Wider context from the report

    “8. The pool was not under continuous supervision and there was no legal requirement for a lifeguard, but it was under CCTV surveillance. However, the camera was placed at such a position that it could not detect what was happening under water, and there was a blind spot in that part of the pool nearest the camera. After Mr Al-Hirsi slipped under water, he was completely invisible to the camera. ”

    Source location

    Kamal Yahyia AL-HIRSI · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure pool-cleaning partners can undertake an emergency water rescue

    Wider context from the report

    “2. No thought appeared to have been given to the fact that the cleaner who often partnered Mr Al-Hirsi in the pool cleaning process, standing on poolside and directing him, was a non swimmer and not confident to enter the water even at a depth of 1.5m. In the event, she relied on a club member to undertake the rescue. ”

    Source location

    Kamal Yahyia AL-HIRSI · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of staff training in the use of pool lifesaving aids

    Wider context from the report

    “3. Members of staff had not been given any water safety awareness training. Some did not have a proper understanding of the ways in which a person in difficulty in the water may present, for example that they will not necessarily wave in distress, and that they may sink rather than float. Mr Al-Hirsi simply sank to the bottom of the pool. Bannatyne’s had not trained staff in the use of pool lifesaving aids. The cleaner who first tried to help Mr Al-Hirsi attempted to poke him with a float, but the float did what it was meant to, it floated. ”

    Source location

    Kamal Yahyia AL-HIRSI · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to teach the lifesaving techniques required by pool procedures

    Wider context from the report

    “10. The written procedures did not detail the action that should be taken on noting a bather in difficulty; they talked about RLSS (Royal Life Saving Society) techniques being used but these were never taught; and the duty manager at the time gave evidence that he did not ever remember reading the standard operating procedures or emergency action plan. Of particular concern to me is that, ten months following Mr Al-Hirsi’s death, many of these practices remain entirely unchanged. For example, evidence was heard that no thought has been given to obtaining another camera; no thought to moving the CCTV monitor; and no thought to giving the staff water safety awareness training. Some refresher training is being given, but this was only started two weeks before the inquest began on Monday, and still no consideration has been given to including the freelance personal trainer (whose response to Mr Al-Hirsi was immediate and effective) in training regarding health and safety procedures within the club. ”

    Source location

    Kamal Yahyia AL-HIRSI · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Reposition Maida Vale pool CCTV cameras and add cameras to remove the identified blind spot.

    Verbatim wording from the response

    “The Company has undertaken a review of its CCTV coverage of the pool at its Maida Vale Club and has commissioned the work for the repositioning of the CCTV cameras. These works will be completed by 31 October 2018 and will include additional cameras to remove the blind spot noted at the Inquest. It should be noted that the purpose of these cameras is to monitor the number of people within the poolside environment as identified in HSG179. The images from these newly positioned cameras will be available to view on the monitor at reception.”

    Source location

    2018-0265-Response-by-Bannatyne-Fitness-Limited
    Page 4 · response
    Published 11 October 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Upskill designated first aiders to obtain pool responder qualifications.

    Verbatim wording from the response

    “It is also the Company’s intention to upskill its designated first aiders to have a pool responder qualification. We will endeavour to complete this by 31 December 2018.”

    Source location

    2018-0265-Response-by-Bannatyne-Fitness-Limited
    Page 1 · response
    Published 11 October 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Require documented Workplace Induction Checklists covering emergency and lifesaving equipment locations and use.

    Verbatim wording from the response

    “The Company also now requires all of its new and existing employees to undertake a documented Workplace Induction Checklist, where they will be given a guided tour of their site to ensure that they are aware of the location and use of the building’s emergency and life saving apparatus. The Company will ensure that all existing employees complete this by 15 November 2018.”

    Source location

    2018-0265-Response-by-Bannatyne-Fitness-Limited
    Page 2 · response
    Published 11 October 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Ensure all existing employees complete the documented Workplace Induction Checklist.

    Verbatim wording from the response

    “The Company also now requires all of its new and existing employees to undertake a documented Workplace Induction Checklist, where they will be given a guided tour of their site to ensure that they are aware of the location and use of the building’s emergency and life saving apparatus. The Company will ensure that all existing employees complete this by 15 November 2018.”

    Source location

    2018-0265-Response-by-Bannatyne-Fitness-Limited
    Page 2 · response
    Published 11 October 2018

    Open published response
  4. Inner North London

    AI-generated summary

    Anthony Cleon GRANT · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Anthony Cleon Grant suffered a cardiac event while swimming in a public pool, drifted to the bottom, and died on poolside after lifeguards attempted resuscitation. The principal concern was that he remained submerged for five minutes and 41 seconds before being noticed, raising issues about lifeguard positioning, the number of lifeguards, and the possible use of motion early warning systems and training footage.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unavailability of a motion early warning system for poolside surveillance

    Wider context from the report

    “Mr Grant drifted under the water and remained submerged for five minutes and 41 seconds before a member of the public noticed him and alerted a lifeguard. The lifeguard had been on duty poolside throughout. Quite apart from the actions of an individual lifeguard, there are many ways that pool safety could have been approached differently that day. The lifeguards could have changed position after half an hour or an hour as had been intended. There could have been more than one lifeguard on poolside. The lifeguards could have been supported by a motion early warning system. These are all matters for the industry to explore. ”

    Source location

    Anthony Cleon GRANT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to change lifeguard positions at planned intervals

    Wider context from the report

    “Mr Grant drifted under the water and remained submerged for five minutes and 41 seconds before a member of the public noticed him and alerted a lifeguard. The lifeguard had been on duty poolside throughout. Quite apart from the actions of an individual lifeguard, there are many ways that pool safety could have been approached differently that day. The lifeguards could have changed position after half an hour or an hour as had been intended. There could have been more than one lifeguard on poolside. The lifeguards could have been supported by a motion early warning system. These are all matters for the industry to explore. ”

    Source location

    Anthony Cleon GRANT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient poolside lifeguard staffing

    Wider context from the report

    “Mr Grant drifted under the water and remained submerged for five minutes and 41 seconds before a member of the public noticed him and alerted a lifeguard. The lifeguard had been on duty poolside throughout. Quite apart from the actions of an individual lifeguard, there are many ways that pool safety could have been approached differently that day. The lifeguards could have changed position after half an hour or an hour as had been intended. There could have been more than one lifeguard on poolside. The lifeguards could have been supported by a motion early warning system. These are all matters for the industry to explore. ”

    Source location

    Anthony Cleon GRANT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  5. Norfolk

    AI-generated summary

    MAYA GRACE KANTENGULE · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Maya Grace Kantengule, aged 7, was found unresponsive at the bottom of a swimming pool during a birthday party on 1 May 2016 and was declared dead later that day. The concerns included the absence of a separate risk assessment for swimming pool birthday parties, failures to follow safety procedures and check compliance, non-functioning CCTV, limited staff awareness of pool-area health and safety, and a lack of formal health and safety training.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to maintain working CCTV for checking the pool area

    Wider context from the report

    “(3) Although safety procedures had not been followed on the morning of the swimming pool party, such as going through safety rules with the pool hirer and signing of documentation, and in addition the CCTV (an additional measure used by WRC to check on the pool area) was known to not be working, no checks were made on the pool party by members of staff to ensure safety rules were understood and followed. ”

    Source location

    MAYA GRACE KANTENGULE · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  6. Blackpool and the Fylde

    AI-generated summary

    Jane Bell · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jane Bell drowned in a hotel swimming pool after going underwater in the deep end and later died in hospital on 14 August 2014. The principal concern was that the hotel’s arrangements for pool supervision, including CCTV monitoring and infrequent poolside patrols, remained insufficient to prevent future deaths, particularly where staff could be distracted and a child could remain underwater for a fatal period.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to maintain constant pool monitoring while reception staff perform other tasks

    Wider context from the report

    “I am concerned that the arrangements which the inquest was told are currently in place at the hotel are such that there remains a risk of future deaths. Although the inquest heard expert evidence to the effect that the requirement that there be constant poolside supervision can be met by a combination of other factors notably poolside patrols and CCTV monitoring and that the hotel aims to provide this, I am concerned that the way in which this is to be delivered is insufficient and the duty to write this report is satisfied. There are now two members of staff employed in the reception area at all times when the pool is open to swimmers. However, although the proposed pool side patrols are to be undertaken at certain parts of the day at 15 minute intervals, at other times when the number of swimmers in the pool is lower these patrols may take place less often and up to a minimum of once per hour. The inquest heard that on the day that Jane Bell died a Leisure Assistant was unable to constantly monitor the pool by way of the CCTV screen / monitor in reception because he was at that time trying to also perform other tasks such as booking guests into the gym, distributing towels etc. The hotel – as confirmed by the Managing Director at the inquest – takes the view that because two staff will now be based in reception that this will ensure those tasks can be performed whilst the other member of staff monitors the pool thereby ensuring constant supervision. I do not find this argument convincing to the extent I am satisfied the duty upon me to write this report is not met. The expert witness told the inquest that he was “not a big fan” of CCTV, and it appears to me that even with two members of staff in the reception area, and given the other tasks such staff have to deal with, it is unlikely that between them the two members of staff will always have the pool in their sight at all times. This is concerning when considered in combination with the proposed pool side patrols. If it was envisaged that such patrols be undertaken at 5 minute intervals throughout times when children may be swimming in the pool, a few moments during which the reception staff may be distracted and dealing with other tasks and not observing the CCTV footage may be less of a concern because a member of staff undertaking patrols at 5 minute intervals would have the chance to observe families, assess if they are complying with the rules set out on signs within the pool area, and recognise whether swimmers who need floatation devices such as arm bands are indeed using them. However, if such patrols take place less frequently the chances of the staff performing those patrols identifying issues that may place a child swimmer at risk are diluted. This appears to be a concern even if the hotel does facilitate patrols at 15 minute intervals as they propose at all times during which the pool is occupied by families. At present, a family may enter the pool and be swimming in the pool for some time, and may be up to an hour, before being observed by a member of staff patrolling the pool area should that family chose to use the pool at a time of low occupancy. This may not be a problem if they are a family who are not safety conscious, are unaware that there is no constant pool side presence, have over-estimated their child’s swimming ability and paid insufficient attention to the pool signage as a result, are not complying with the hotel regulations for whatever reason. A problem then arises is if that family is allowing a child to swim alone or in the deeper half of the pool or without floatation aids when they need one. Jane Bell was under the water for slightly less than two minutes and this proved fatal. I am concerned that reception desk staff may be distracted for a similar time leaving them unable – in spite of the encouraging work that has been undertaken since this fatality to train leisure and entertainment staff in first aid and pool side rescue which the expert witness felt ought to enable staff to effect a pool rescue – to rescue a child and prevent a similar fatality. The time needed to assist a child under the water is limited and poolside safety equipment at the hotel is limited to devices that may be used to assist someone struggling on the surface but not necessarily a child under the water. The impression given during evidence at the inquest was that the hotel management felt that there is a marked difference between time of high pool occupancy and other times when the use of the pool is much less. The concern about future deaths does not arise in respect of times when the pool is empty or when only adults are using it. The concern arises when perhaps only one or two families are using the pool. The evidence provided at the inquest suggested that at such times, pool side patrols would take place much less often than at fifteen minute intervals and I am concerned that more infrequent patrols – when families are using the pool – would not satisfy the requirement for constant supervision. Indeed as the expert witness stated at the inquest, he was of the opinion that such patrols ought to be conducted at five minute intervals. At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Trust by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009. ”

    Source location

    Jane Bell · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient frequency of poolside patrols when families use the pool

    Wider context from the report

    “I am concerned that the arrangements which the inquest was told are currently in place at the hotel are such that there remains a risk of future deaths. Although the inquest heard expert evidence to the effect that the requirement that there be constant poolside supervision can be met by a combination of other factors notably poolside patrols and CCTV monitoring and that the hotel aims to provide this, I am concerned that the way in which this is to be delivered is insufficient and the duty to write this report is satisfied. There are now two members of staff employed in the reception area at all times when the pool is open to swimmers. However, although the proposed pool side patrols are to be undertaken at certain parts of the day at 15 minute intervals, at other times when the number of swimmers in the pool is lower these patrols may take place less often and up to a minimum of once per hour. The inquest heard that on the day that Jane Bell died a Leisure Assistant was unable to constantly monitor the pool by way of the CCTV screen / monitor in reception because he was at that time trying to also perform other tasks such as booking guests into the gym, distributing towels etc. The hotel – as confirmed by the Managing Director at the inquest – takes the view that because two staff will now be based in reception that this will ensure those tasks can be performed whilst the other member of staff monitors the pool thereby ensuring constant supervision. I do not find this argument convincing to the extent I am satisfied the duty upon me to write this report is not met. The expert witness told the inquest that he was “not a big fan” of CCTV, and it appears to me that even with two members of staff in the reception area, and given the other tasks such staff have to deal with, it is unlikely that between them the two members of staff will always have the pool in their sight at all times. This is concerning when considered in combination with the proposed pool side patrols. If it was envisaged that such patrols be undertaken at 5 minute intervals throughout times when children may be swimming in the pool, a few moments during which the reception staff may be distracted and dealing with other tasks and not observing the CCTV footage may be less of a concern because a member of staff undertaking patrols at 5 minute intervals would have the chance to observe families, assess if they are complying with the rules set out on signs within the pool area, and recognise whether swimmers who need floatation devices such as arm bands are indeed using them. However, if such patrols take place less frequently the chances of the staff performing those patrols identifying issues that may place a child swimmer at risk are diluted. This appears to be a concern even if the hotel does facilitate patrols at 15 minute intervals as they propose at all times during which the pool is occupied by families. At present, a family may enter the pool and be swimming in the pool for some time, and may be up to an hour, before being observed by a member of staff patrolling the pool area should that family chose to use the pool at a time of low occupancy. This may not be a problem if they are a family who are not safety conscious, are unaware that there is no constant pool side presence, have over-estimated their child’s swimming ability and paid insufficient attention to the pool signage as a result, are not complying with the hotel regulations for whatever reason. A problem then arises is if that family is allowing a child to swim alone or in the deeper half of the pool or without floatation aids when they need one. Jane Bell was under the water for slightly less than two minutes and this proved fatal. I am concerned that reception desk staff may be distracted for a similar time leaving them unable – in spite of the encouraging work that has been undertaken since this fatality to train leisure and entertainment staff in first aid and pool side rescue which the expert witness felt ought to enable staff to effect a pool rescue – to rescue a child and prevent a similar fatality. The time needed to assist a child under the water is limited and poolside safety equipment at the hotel is limited to devices that may be used to assist someone struggling on the surface but not necessarily a child under the water. The impression given during evidence at the inquest was that the hotel management felt that there is a marked difference between time of high pool occupancy and other times when the use of the pool is much less. The concern about future deaths does not arise in respect of times when the pool is empty or when only adults are using it. The concern arises when perhaps only one or two families are using the pool. The evidence provided at the inquest suggested that at such times, pool side patrols would take place much less often than at fifteen minute intervals and I am concerned that more infrequent patrols – when families are using the pool – would not satisfy the requirement for constant supervision. Indeed as the expert witness stated at the inquest, he was of the opinion that such patrols ought to be conducted at five minute intervals. At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Trust by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009. ”

    Source location

    Jane Bell · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient poolside equipment for rescuing a submerged child

    Wider context from the report

    “I am concerned that the arrangements which the inquest was told are currently in place at the hotel are such that there remains a risk of future deaths. Although the inquest heard expert evidence to the effect that the requirement that there be constant poolside supervision can be met by a combination of other factors notably poolside patrols and CCTV monitoring and that the hotel aims to provide this, I am concerned that the way in which this is to be delivered is insufficient and the duty to write this report is satisfied. There are now two members of staff employed in the reception area at all times when the pool is open to swimmers. However, although the proposed pool side patrols are to be undertaken at certain parts of the day at 15 minute intervals, at other times when the number of swimmers in the pool is lower these patrols may take place less often and up to a minimum of once per hour. The inquest heard that on the day that Jane Bell died a Leisure Assistant was unable to constantly monitor the pool by way of the CCTV screen / monitor in reception because he was at that time trying to also perform other tasks such as booking guests into the gym, distributing towels etc. The hotel – as confirmed by the Managing Director at the inquest – takes the view that because two staff will now be based in reception that this will ensure those tasks can be performed whilst the other member of staff monitors the pool thereby ensuring constant supervision. I do not find this argument convincing to the extent I am satisfied the duty upon me to write this report is not met. The expert witness told the inquest that he was “not a big fan” of CCTV, and it appears to me that even with two members of staff in the reception area, and given the other tasks such staff have to deal with, it is unlikely that between them the two members of staff will always have the pool in their sight at all times. This is concerning when considered in combination with the proposed pool side patrols. If it was envisaged that such patrols be undertaken at 5 minute intervals throughout times when children may be swimming in the pool, a few moments during which the reception staff may be distracted and dealing with other tasks and not observing the CCTV footage may be less of a concern because a member of staff undertaking patrols at 5 minute intervals would have the chance to observe families, assess if they are complying with the rules set out on signs within the pool area, and recognise whether swimmers who need floatation devices such as arm bands are indeed using them. However, if such patrols take place less frequently the chances of the staff performing those patrols identifying issues that may place a child swimmer at risk are diluted. This appears to be a concern even if the hotel does facilitate patrols at 15 minute intervals as they propose at all times during which the pool is occupied by families. At present, a family may enter the pool and be swimming in the pool for some time, and may be up to an hour, before being observed by a member of staff patrolling the pool area should that family chose to use the pool at a time of low occupancy. This may not be a problem if they are a family who are not safety conscious, are unaware that there is no constant pool side presence, have over-estimated their child’s swimming ability and paid insufficient attention to the pool signage as a result, are not complying with the hotel regulations for whatever reason. A problem then arises is if that family is allowing a child to swim alone or in the deeper half of the pool or without floatation aids when they need one. Jane Bell was under the water for slightly less than two minutes and this proved fatal. I am concerned that reception desk staff may be distracted for a similar time leaving them unable – in spite of the encouraging work that has been undertaken since this fatality to train leisure and entertainment staff in first aid and pool side rescue which the expert witness felt ought to enable staff to effect a pool rescue – to rescue a child and prevent a similar fatality. The time needed to assist a child under the water is limited and poolside safety equipment at the hotel is limited to devices that may be used to assist someone struggling on the surface but not necessarily a child under the water. The impression given during evidence at the inquest was that the hotel management felt that there is a marked difference between time of high pool occupancy and other times when the use of the pool is much less. The concern about future deaths does not arise in respect of times when the pool is empty or when only adults are using it. The concern arises when perhaps only one or two families are using the pool. The evidence provided at the inquest suggested that at such times, pool side patrols would take place much less often than at fifteen minute intervals and I am concerned that more infrequent patrols – when families are using the pool – would not satisfy the requirement for constant supervision. Indeed as the expert witness stated at the inquest, he was of the opinion that such patrols ought to be conducted at five minute intervals. At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Trust by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009. ”

    Source location

    Jane Bell · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide constant poolside supervision through trained patrol and reception CCTV monitoring whenever the pool is open.

    Verbatim wording from the response

    “Since the inquest the Hotel has had constant poolside supervision in place at all times when the pool is open regardless of whether it is in use. This involves one member of staff (with poolside responder training) constantly patrolling at the poolside and another member of staff (also poolside responder trained) continually monitoring the CCTV footage from the reception desk.”

    Source location

    Jane-Bell-Response
    Page 1 · response
    Published 22 March 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Carry out documented opening and closing pool-hall safety inspections covering rescue equipment, water clarity, lighting, signage and staff communications.

    Verbatim wording from the response

    “In addition to this there are documented pool hall safety checks and inspections carried out on opening and closing. These inspections consist of checking the water rescue equipment, looking at the water clarity and lighting and signage and also require the communication folder to be read. The communication folder updates members of staff as to any changes or issues with the pool the previous day.”

    Source location

    Jane-Bell-Response
    Page 2 · response
    Published 22 March 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Constant supervision will cease after reducing pool depth because none of the other HSG79 criteria applies.

    Verbatim wording from the response

    “The requirement for constant supervision under HSG79 will cease once the depth of the pool is reduced as none of the other criteria within the guidance applies. However, the CCTV will continue to be monitored to ensure that bathers are complying with the rules and regular bather head counts will be taken. Pool water testing will also remain at 2 hourly intervals and during these checks staff will monitor the pool and those in it.”

    Source location

    Jane-Bell-Response
    Page 2 · response
    Published 22 March 2016

    Open published response
  7. Manchester West

    AI-generated summary

    Loui Aspinall · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Loui Aspinall died after walking into a swimming pool at a hotel resort in Tunisia and becoming submerged. The concerns included the apparent absence of obvious resuscitation and rescue equipment, uncertainty about lifeguard provision and first-aid training, and gaps in tour-operator best-practice guidance on pool safety and emergency procedures.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of best-practice requirements for first-aid-trained swimming-pool lifeguards

    Wider context from the report

    “i. Best practice guidelines issued by the Federation of British Tour Operators do not appear to include a requirement for the presence of a lifeguard at a swimming pool trained in first aid and the provisions of resuscitation equipment and rescue equipment in obvious and designated areas around a swimming pool. ”

    Source location

    Loui Aspinall · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of best-practice requirements for resuscitation equipment at swimming pools

    Wider context from the report

    “i. Best practice guidelines issued by the Federation of British Tour Operators do not appear to include a requirement for the presence of a lifeguard at a swimming pool trained in first aid and the provisions of resuscitation equipment and rescue equipment in obvious and designated areas around a swimming pool. ”

    Source location

    Loui Aspinall · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of best-practice requirements for rescue equipment at swimming pools

    Wider context from the report

    “i. Best practice guidelines issued by the Federation of British Tour Operators do not appear to include a requirement for the presence of a lifeguard at a swimming pool trained in first aid and the provisions of resuscitation equipment and rescue equipment in obvious and designated areas around a swimming pool. ”

    Source location

    Loui Aspinall · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  8. Essex

    AI-generated summary

    Josephine Foday and Komba Kpakiwa · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Josephine Foday and Komba Kpakiwa were found floating in the swimming pool at Down Hall Country House Hotel, and their deaths were confirmed shortly afterwards. The inquests concluded that the deaths were accidental and that the cause of death for both was consistent with drowning. Concerns included the pool’s dangerous profile, inadequate risk assessments and signage, lack of lifeguards and trained aquatic-rescue staff, and ineffective supervision arrangements, including unmonitored CCTV.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure trained aquatic rescue staff are present when the pool is open

    Wider context from the report

    “8) The pool operators did not ensure that in a pool of over 1.5m depth there were always on the premises, when the pool was open, staff trained in aquatic rescue techniques. ”

    Source location

    Josephine Foday and Komba Kpakiwa · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to obtain swimming pool expert advice on controls for unsupervised pool use

    Wider context from the report

    “6) The pool operators had not sought the advice of a swimming pool expert in order to decide what would constitute adequate controls where constant pool supervision was not provided in this unusual hopper type pool. The operators were relying on CCTV as a method of supervision but this was not monitored and no system was put in its place when it became unavailable. ”

    Source location

    Josephine Foday and Komba Kpakiwa · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The swimming pool is closed, so no one else will be exposed to a similar risk at that facility.

    Verbatim wording from the response

    “We understand that the swimming pool concerned is now closed and so no-one else will be put at similar risk in this facility.”

    Source location

    2014-0301-Response-by-IOSH
    Page 1 · response
    Published 23 May 2014

    Open published response
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Data last updated 7 September 2026