23 May 2014 Josephine Foday and Komba Kpakiwa · Prevention of Future Deaths report Essex
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Concerns raised 8 Failure to ensure trained aquatic rescue staff are present when the pool is open View source Inherently dangerous pool profile View source Unclear, inaccurate and ambiguous pool signage View source Failure to obtain swimming pool expert advice on controls for unsupervised pool use View source Failure to provide lifeguards or effective drowning-risk controls View source Failure to consider non-swimmers and poor swimmers in risk assessments View source Failure to assess the pool profile and specific risk factors View source Failure to monitor CCTV supervision and provide a contingency when unavailable View source See 5 more concerns
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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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. The report was sent to The Chartered Institute of Environmental Health; that does not assign responsibility.
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.
” 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 Chartered Institute of Environmental Health; that does not assign responsibility.
PFD Monitor interpretation Inherently dangerous pool profile
Wider context from the report “1) The pool profile 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 Chartered Institute of Environmental Health; that does not assign responsibility.
PFD Monitor interpretation Unclear, inaccurate and ambiguous pool signage
Wider context from the report “7) Some of the signage provided was not clear, accurate and unambiguous .
” 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 Chartered Institute of Environmental Health; that does not assign responsibility.
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.
” 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 Chartered Institute of Environmental Health; that does not assign responsibility.
PFD Monitor interpretation Failure to provide lifeguards or effective drowning-risk controls
Wider context from the report “4) There were no lifeguards provided and the duty holders of the pool did not ensure that there were in place effective controls in place to reduce the risk of drowning
” 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 Chartered Institute of Environmental Health; that does not assign responsibility.
PFD Monitor interpretation Failure to consider non-swimmers and poor swimmers in risk assessments
Wider context from the report “5) It did not appear that non swimmers or poor swimmers had been considered in the risk assessment process .
” 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 Chartered Institute of Environmental Health; that does not assign responsibility.
PFD Monitor interpretation Failure to assess the pool profile and specific risk factors
Wider context from the report “2) The pool profile, including depths and gradients were not considered when carrying out the hazard identification that is required in the swimming pool guidance document HSG 179
3) The risk assessments did not cover the accurate profile information and any other specific risk factors
” 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 Chartered Institute of Environmental Health; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor CCTV supervision and provide a contingency when unavailable
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 .
” 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