PFD report

Robin van Caliskan · Prevention of Future Deaths report

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Issued 18 Sep 2024•Cornwall and Isles of Scilly

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Failure to provide lifeguarding services in the pool except when large inflatables were permitted
    Part of recurring concern: Inadequate controls for drowning risks in swimming pools
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Action

    Reconsider lifeguard provision during annual risk assessment reviews and when significant changes or other events indicate that review is required.

    Stated by Atlantic Reach LimitedStated in progressThe respondent said that this action was in progress when they made their response on 19 September 2024.
  2. Action

    Review the swimming pool risk assessments in light of the inquest evidence and applicable HSG 179 guidance.

    Stated by Atlantic Reach LimitedStated completedThe respondent said that this action was complete when they made their response on 19 September 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Existing alternative control measures are considered sufficient because HSG 179 permits them where lifeguarding is not reasonably practicable.

    Stated by Atlantic Reach LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide lifeguarding services in the pool except when large inflatables were permitted

Wider context from the report

“1) A risk assessment conducted by the company that took account of existing Health & Safety Guidance concluded that it was not reasonably practicable to use lifeguards except on the relatively few occasions when large inflatables were permitted in the pool. 2) While there was felt to be compliance with existing minimum legal standards, a Health & Safety enforcement officer with Cornwall Council felt this was borderline. She observed that similar sized companies elsewhere did provide a lifeguarding service. She felt lessons had not been learned and said that the company should be doing more. ”

Is this part of a recurring concern?

Yes — Inadequate controls for drowning risks in swimming pools.

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Reconsider lifeguard provision during annual risk assessment reviews and when significant changes or other events indicate that review is required.

Verbatim wording from the response

“The Company has concluded that it is not reasonably practicable to provide lifeguard supervision at this time. This position will remain under constant review and will be reconsidered –”

Source location

Response from Atlantic Reach
Page 5 · response
Published 19 September 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review the swimming pool risk assessments in light of the inquest evidence and applicable HSG 179 guidance.

Verbatim wording from the response

“The Company confirms that it has reviewed its swimming pool risk assessments since the inquest and in light of the evidence that was heard. It has again had regard to HSG 179 and the requirement to ensure the safety of pool users so far as is reasonably practicable.”

Source location

Response from Atlantic Reach
Page 4 · response
Published 19 September 2024

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Existing alternative control measures are considered sufficient because HSG 179 permits them where lifeguarding is not reasonably practicable.

Verbatim wording from the response

“The evidence was that the Company had adopted the guidance set out in HSE Guidance HSG 179, Health and Safety in Swimming Pools, and had concluded that the provision of lifeguards was not”

Source location

Response from Atlantic Reach
Page 2 · response
Published 19 September 2024

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Providing lifeguard supervision is considered not reasonably practicable because qualified staff shortages, recruitment disruption, supervision risks and substantial costs constrain delivery.

Verbatim wording from the response

“The practicalities of providing lifeguards:”

Source location

Response from Atlantic Reach
Page 5 · response
Published 19 September 2024

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. 1

    Communicate the absence of lifeguards and pool safety requirements through swimming pool timetables and a dedicated website safety page.

    Stated by Atlantic Reach LimitedStated completedThe respondent said that this action was complete when they made their response on 19 September 2024.
  2. 2

    Review and develop health and safety procedures regularly as necessary to maintain their effectiveness and compliance.

    Stated by Atlantic Reach LimitedStated plannedThe respondent said that this action was planned when they made their response on 19 September 2024.
  3. 3

    Install a dedicated swimming pool first aid kit in the Leisure reception area.

    Stated by Atlantic Reach LimitedStated completedThe respondent said that this action was complete when they made their response on 19 September 2024.
  4. 4

    Update and implement a robust training programme for Leisure staff involved in pool rescues or poolside emergency treatment.

    Stated by Atlantic Reach LimitedStated completedThe respondent said that this action was complete when they made their response on 19 September 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.4

  1. 1

    The company disputes unsupported comparisons with other pool operators and any suggestion that it has a higher accident rate.

    Stated by Atlantic Reach LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    The company disputes that its health and safety compliance was borderline, stating it complied with relevant legislation and guidance.

    Stated by Atlantic Reach LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  3. 3

    The company disputes that lessons were not learned from the 2020 incident, stating it reviewed the relevant safety measures.

    Stated by Atlantic Reach LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  4. 4

    If HSG 179 is insufficiently clear or stringent, responsibility for addressing that guidance lies with the HSE.

    Stated by Atlantic Reach LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Communicate the absence of lifeguards and pool safety requirements through swimming pool timetables and a dedicated website safety page.

Verbatim wording from the response

“The Company has also reviewed the control measures currently in place. In addition to the controls referred to in Mr Vernon's statement, the Company has now also –”

Source location

Response from Atlantic Reach
Page 5 · response
Published 19 September 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review and develop health and safety procedures regularly as necessary to maintain their effectiveness and compliance.

Verbatim wording from the response

“The Company wishes to emphasise that it takes the safety of its pool users – and all guests at the site – extremely seriously. The Company would have carried out the review described above even if HM Senior Coroner had decided not to issue the PFD report. The Company appreciates that the management of health and safety is an ongoing duty and confirms that its procedures will be reviewed regularly and developed as necessary to ensure they remain effective and compliant.”

Source location

Response from Atlantic Reach
Page 6 · response
Published 19 September 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Install a dedicated swimming pool first aid kit in the Leisure reception area.

Verbatim wording from the response

“- Installed a dedicated swimming pool first aid kit in the Leisure reception area.”

Source location

Response from Atlantic Reach
Page 6 · response
Published 19 September 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Update and implement a robust training programme for Leisure staff involved in pool rescues or poolside emergency treatment.

Verbatim wording from the response

“- Updated and implemented a robust training programme for Leisure staff who may be involved in pool rescues or poolside emergency treatment.”

Source location

Response from Atlantic Reach
Page 6 · response
Published 19 September 2024

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The company disputes unsupported comparisons with other pool operators and any suggestion that it has a higher accident rate.

Verbatim wording from the response

“In the PFD Report, HM Coroner refers to the Enforcement Officer’s evidence “that similar sized companies elsewhere did provide a lifeguarding service.””

Source location

Response from Atlantic Reach
Page 3 · response
Published 19 September 2024

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The company disputes that its health and safety compliance was borderline, stating it complied with relevant legislation and guidance.

Verbatim wording from the response

“The Company expressed its concern regarding the making of a report in circumstances where the evidence, including that of the Enforcement Officer for Cornwall Council and the Investigating Police Officer, was that at the time of the incident, the Company complied with the requirements of relevant health and safety legislation and guidance. Although the Enforcement Officer had described compliance at the date of the incident as “borderline”, that was not accepted by the Company, did not reflect the position at the date of the inquest – by which time further measures had been implemented – and in any event is not a term which is recognised amongst health and safety professionals.”

Source location

Response from Atlantic Reach
Page 2 · response
Published 19 September 2024

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The company disputes that lessons were not learned from the 2020 incident, stating it reviewed the relevant safety measures.

Verbatim wording from the response

“The specific recommendation in the letter was that the Enforcement Officer “would advise Atlantic Reach to review some of your policies / procedures and that consideration is given to changing your current poolside supervision or observation methods of the pool to prevent a similar reoccurrence”.”

Source location

Response from Atlantic Reach
Page 4 · response
Published 19 September 2024

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

If HSG 179 is insufficiently clear or stringent, responsibility for addressing that guidance lies with the HSE.

Verbatim wording from the response

“It was submitted that in so far as HM Senior Coroner was concerned, if HSG 179 itself was not sufficiently clear or stringent, that was a matter for the HSE, since similar issues would arise in relation to many other pools in similar circumstances.”

Source location

Response from Atlantic Reach
Page 3 · response
Published 19 September 2024

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026