8 Aug 2017 MAYA GRACE KANTENGULE · Prevention of Future Deaths report Norfolk
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Concerns raised 7 Lack of staff health and safety awareness in the pool area View source Failure to maintain working CCTV for checking the pool area View source Failure to risk-assess swimming pool birthday parties View source Failure to check pool parties for understanding and compliance with safety rules View source Failure to complete required pool-hirer safety briefing and documentation View source Failure to provide formal health and safety training to responsible personnel and staff View source Lack of formal health and safety training for directors and staff View source See 4 more concerns
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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.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ACR Leisure Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of staff health and safety awareness in the pool area
Wider context from the report “(4) There was no evidence of awareness of staff with regard to health and safety in the pool area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ACR Leisure Limited; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ACR Leisure Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to risk-assess swimming pool birthday parties
Wider context from the report “(1) Prior to Maya’s death in 2004, independent Contractors had drawn up the Risk Assessments and other Health and Safety documentation relating to the organisation and the use of its facilities by staff and the public. Since 2011, the Risk Assessments were updated internally. These had been deemed “suitable and correct” by South Norfolk Council. Since 2004 there had been no formal Health and Safety Training of Directors or staff at Waveney River Centre (WRC), in particular by those responsible for health and safety and by those updating, reviewing and checking health and safety documentation.
(2) Although a Risk Assessment had been completed and updated with regard to the use of the swimming pool in 2016, there was no separate Risk Assessment in place with regard to the holding of swimming pool birthday parties . It was clear from the evidence it was believed by those at WRC to be the responsibility of the person holding the birthday party who would be responsible for the safety of the guests.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ACR Leisure Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to check pool parties for understanding and compliance with safety rules
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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ACR Leisure Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to complete required pool-hirer safety briefing and documentation
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ACR Leisure Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide formal health and safety training to responsible personnel and staff
Wider context from the report “(5) Since Maya’s death, the decision has been made to hold no further external pool parties. The Swimming pool is still used by the public and WRC is still involved in activities involving the public and water.
(6) Fourteen months have passed since Maya’s death and there has been no formal health and safety training of Directors and staff. It was said on behalf of WRC they are awaiting the outcome of the inquest before arranging formal health and safety training and in addition the member of staff responsible for updating and reviewing Risk Assessments has suffered with PTSD as a result of Maya’s death. There was no indication that anyone else had been considered in respect of undergoing health and safety training, such as those ultimately responsible for health and safety at WRC or any other member of staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to ACR Leisure Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of formal health and safety training for directors and staff
Wider context from the report “(1) Prior to Maya’s death in 2004, independent Contractors had drawn up the Risk Assessments and other Health and Safety documentation relating to the organisation and the use of its facilities by staff and the public. Since 2011, the Risk Assessments were updated internally. These had been deemed “suitable and correct” by South Norfolk Council. Since 2004 there had been no formal Health and Safety Training of Directors or staff at Waveney River Centre (WRC), in particular by those responsible for health and safety and by those updating, reviewing and checking health and safety documentation.
(2) Although a Risk Assessment had been completed and updated with regard to the use of the swimming pool in 2016, there was no separate Risk Assessment in place with regard to the holding of swimming pool birthday parties. It was clear from the evidence it was believed by those at WRC to be the responsibility of the person holding the birthday party who would be responsible for the safety of the guests.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations