24 Oct 2018 Catherine Mary GIBBON · Prevention of Future Deaths report Inner North London
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Concerns raised 11 Failure to train and guide reception staff in CCTV monitoring View source Inadequate CCTV screen visibility for pool activity View source Unavailability of continuous monitoring for swimmers with epilepsy View source Failure to maintain CCTV cameras and provide alternative surveillance when one is non-operational View source Failure to share and act on learning from comparable pool deaths View source Unavailability of a defibrillator at poolside View source Failure to prevent first aid certificate lapses through a failsafe renewal system View source Lack of clear arrangements for additional help for swimmers with epilepsy View source Absence of a building-wide audible emergency alarm View source Lack of clear guidance and staff understanding of medical conditions relevant to exercise View source Absence of immediate poolside telephone access for summoning medical assistance View source See 8 more concerns
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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.
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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 ukactive; that does not assign responsibility.
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 .
” 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 ukactive; that does not assign responsibility.
PFD Monitor interpretation Inadequate CCTV screen visibility for pool activity
Wider context from the report “4. The receptionist also gave evidence that in her opinion, the screens (the monitor was split into four screens for the four cameras) were too small to see the pool activity clearly.
” 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 ukactive; that does not assign responsibility.
PFD Monitor interpretation Unavailability of continuous monitoring for swimmers with epilepsy
Wider context from the report “2. There was also no clear understanding across staff of what additional help, if any, could be offered to a swimmer with epilepsy. Any understanding seemed to concentrate upon Ms Gibbon obtaining a doctor’s letter authorising swimming.
Whilst there is of course merit in prompting a discussion with a potential swimmer’s doctor about the advisability of swimming, Fitness First indicated that constant monitoring of such a swimmer will not be offered .
” 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 ukactive; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain CCTV cameras and provide alternative surveillance when one is non-operational
Wider context from the report “5. In fact, one of the four cameras had been broken since 24 May. It had not reported and no alternative measures had been taken since it had become non operational.
” 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 ukactive; that does not assign responsibility.
PFD Monitor interpretation Failure to share and act on learning from comparable pool deaths
Wider context from the report “Fitness First have taken steps to address some of these issues, and told me that such learning is shared at a national level. However, at inquest Fitness First national lead for health and safety told me that he was unaware that I sent a prevention of future deaths report to Bannatyne’s on 13 August 2018, regarding a death in similar circumstances in Maida Vale on 10 October 2017. I did copy this report to Swim England, but this does not appear to have prompted a national conversation among private pool providers .
I leave that now with UK Active.
” 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 ukactive; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a defibrillator at poolside
Wider context from the report “8. There was a defibrillator in the gym, but there was not another at poolside .
” 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 ukactive; that does not assign responsibility.
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 .
” 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 ukactive; that does not assign responsibility.
PFD Monitor interpretation Lack of clear arrangements for additional help for swimmers with epilepsy
Wider context from the report “2. There was also no clear understanding across staff of what additional help, if any, could be offered to a swimmer with epilepsy . Any understanding seemed to concentrate upon Ms Gibbon obtaining a doctor’s letter authorising swimming.
Whilst there is of course merit in prompting a discussion with a potential swimmer’s doctor about the advisability of swimming, Fitness First indicated that constant monitoring of such a swimmer will not be offered.
” 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 ukactive; that does not assign responsibility.
PFD Monitor interpretation Absence of a building-wide audible emergency alarm
Wider context from the report “6. There was no panic button that would activate 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 .
” 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 ukactive; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance and staff understanding of medical conditions relevant to exercise
Wider context from the report “1. When Ms Gibbon joined the gym, she was given a health pledge to read. In this, she agreed to inform a member of staff if she had a medical condition that might interfere with exercise. However, she was not given any assistance in understanding which medical conditions would come in to this category . Even the staff taking her through the health pledge did not have a clear understanding of this .
” 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 ukactive; that does not assign responsibility.
PFD Monitor interpretation Absence of immediate poolside telephone access for summoning medical assistance
Wider context from the report “7. There was no landline at poolside that could be used to call an ambulance in case of emergency , to enable medical assistance to be summoned immediately by someone who actually had sight of the casualty .
” 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