13 Aug 2018 Kamal Yahyia AL-HIRSI · Prevention of Future Deaths report Inner North London
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Concerns raised 14 Failure of written procedures to specify action for a bather in difficulty View source CCTV failing to provide visibility of the pool underwater and in blind spots View source Failure of the alarm-response process to provide trained responders with the nature of the emergency View source Failure of emergency communication routes to reliably contact the duty manager View source Failure of panic-button alarms to alert staff throughout the building View source Failure to ensure staff know the location and use of panic buttons View source Failure to maintain effective CCTV monitoring of the pool View source Failure to ensure the duty manager reads the standard operating procedures and emergency action plan View source Failure to ensure pool-cleaning partners can undertake an emergency water rescue View source Lack of staff defibrillator location and use training View source Lack of safe pool-cleaning equipment View source Lack of staff training in the use of pool lifesaving aids View source Failure to teach the lifesaving techniques required by pool procedures View source Lack of staff water safety awareness training View source See 11 more concerns
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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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations