The Bannatyne Group Limited

Private and voluntary organisations · Company

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First report 13 Aug 2018•Latest report 13 Aug 2018

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

Statements from The Bannatyne Group Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

13 Aug2018
Inner North London
Concerns raised14
1. Failure of written procedures to specify action for a bather in difficulty
2. CCTV failing to provide visibility of the pool underwater and in blind spots
3. Failure of the alarm-response process to provide trained responders with the nature of the emergency
1. Failure of emergency communication routes to reliably contact the duty manager
2. Failure of panic-button alarms to alert staff throughout the building
3. Failure to ensure staff know the location and use of panic buttons
4. Failure to maintain effective CCTV monitoring of the pool
5. Failure to ensure the duty manager reads the standard operating procedures and emergency action plan
6. Failure to ensure pool-cleaning partners can undertake an emergency water rescue
7. Lack of staff defibrillator location and use training
8. Lack of safe pool-cleaning equipment
9. Lack of staff training in the use of pool lifesaving aids
10. Failure to teach the lifesaving techniques required by pool procedures
11. Lack of staff water safety awareness training
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
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. The report was sent to The Bannatyne Group Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure of written procedures to specify action for a bather in difficulty
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. ”
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 The Bannatyne Group Limited; that does not assign responsibility.
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. ”
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 The Bannatyne Group Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure of the alarm-response process to provide trained responders with the nature of the emergency
Wider context from the report
“5. The panic button alarm was audible by a beeping sound in reception and a light was illuminated on a control panel there, but this relied solely on the reactions of one individual who was not necessarily first aid trained and, if the receptionist did call 999, s/he would not necessarily know the nature of the emergency. In this instance, the receptionist who called an ambulance did not know that Mr Al-Hirsi had suffered a cardiac arrest. ”
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 The Bannatyne Group Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure of emergency communication routes to reliably contact the duty manager
Wider context from the report
“6. The protocol in place was that, on hearing an alarm, the receptionist should simply contact the duty manager (who was the designated site first aider): first by radio; failing that by sending someone to find him; and failing that by ringing the duty manager’s mobile phone. The receptionist gave evidence that the radios often didn’t work, though the regional manager disagreed. When the receptionist was notified that there was an emergency, she could not use the radio because the duty manager had not picked a radio up; she was unsure where he was; and when she rang him on his mobile, she did not get through because there is a poor reception in the plant room where he was working. ”
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 The Bannatyne Group Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure of panic-button alarms to alert staff throughout the building
Wider context from the report
“4. Some members of staff did not know the exact location of the panic buttons, nor the circumstances in which they should be pressed. The panic buttons did not sound an audible alarm throughout the building, so anyone pressing a button would not know if it had alerted others, and staff elsewhere (other than at reception) would be unaware that there was an emergency. It did not occur to the cleaner who first realised that Mr Al-Hirsi was in difficulty to press the alarm, but even if she had, this would not have brought other staff running to help. ”
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 The Bannatyne Group Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure staff know the location and use of panic buttons
Wider context from the report
“4. Some members of staff did not know the exact location of the panic buttons, nor the circumstances in which they should be pressed. The panic buttons did not sound an audible alarm throughout the building, so anyone pressing a button would not know if it had alerted others, and staff elsewhere (other than at reception) would be unaware that there was an emergency. It did not occur to the cleaner who first realised that Mr Al-Hirsi was in difficulty to press the alarm, but even if she had, this would not have brought other staff running to help. ”
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 The Bannatyne Group Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain effective CCTV monitoring of the pool
Wider context from the report
“9. The CCTV monitor was in reception. This was meant to be observed every 15 minutes (to ensure maximum bather load had not been exceeded, rather than to look for bathers in distress), but these observations had fallen out of practice, and the monitor was behind the head of the receptionist, so it was never in her normal field of view. She had to turn her back on the public to look at it. ”
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 The Bannatyne Group Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure the duty manager reads the standard operating procedures and emergency action plan
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. ”
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 The Bannatyne Group Limited; that does not assign responsibility.
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. ”
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 The Bannatyne Group Limited; that does not assign responsibility.
PFD Monitor interpretation
Lack of staff defibrillator location and use training
Wider context from the report
“7. There seemed a lack of meaningful awareness of the defibrillator location and function. The first person trained in CPR (cardiopulmonary resuscitation) to respond to the calls for help was a freelance personal trainer who was not a member of Bannatyne staff. Although he was trained, he did not take the defibrillator (there was only one and it was located in the gym) with him, because at that stage he did not know that Mr Al-Hirsi had suffered a cardiac arrest. Some staff members had not received defibrillator training. When the personal trainer reached Mr Al-Hirsi and realised the exact nature of the emergency, the only other person on poolside at that point who seemed confident of the location of the defibrillator, was a club member who happened to be a retired doctor. ”
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 The Bannatyne Group Limited; that does not assign responsibility.
PFD Monitor interpretation
Lack of safe pool-cleaning equipment
Wider context from the report
“1. Mr Al-Hirsi cleaned the pool by diving down with a suction hose and holding his breath. This had always been the method at Maida Vale, because there was no pole or extension head. Whilst this did not have an impact on Mr Al-Hirsi’s death, evidence was heard that it was inherently dangerous. ”
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 The Bannatyne Group Limited; that does not assign responsibility.
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. ”
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 The Bannatyne Group Limited; that does not assign responsibility.
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. ”
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 The Bannatyne Group Limited; that does not assign responsibility.
PFD Monitor interpretation
Lack of staff water safety awareness training
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. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised14

Failure of written procedures to specify action for a bather in difficulty

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

Failure of the alarm-response process to provide trained responders with the nature of the emergency

Failure of emergency communication routes to reliably contact the duty manager

Failure of panic-button alarms to alert staff throughout the building

Failure to ensure staff know the location and use of panic buttons

Failure to maintain effective CCTV monitoring of the pool

Failure to ensure the duty manager reads the standard operating procedures and emergency action plan

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

Lack of staff defibrillator location and use training

Lack of safe pool-cleaning equipment

Lack of staff training in the use of pool lifesaving aids

Failure to teach the lifesaving techniques required by pool procedures

Lack of staff water safety awareness training