Josephine Foday and Komba Kpakiwa · Prevention of Future Deaths report

On 29 April 2013 I commenced an investigation into the deaths of Josephine Foday and Komba Kpakiwa. The investigation concluded at the end of the inquests on 15 May 2014. The conclusions of the inquests were Accident. Natural The cause of death for both 1a) consistent with drowning.

Both Ms Foday and Mr Komba were found floating in the swimming pool at Down Hall Country House Hotel, Hatfield Heath, Essex. Their deaths were confirmed shortly thereafter.

1) The pool profile was inherently dangerous
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
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
5) It did not appear that non swimmers or poor swimmers had been considered in the risk assessment process.
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.
7) Some of the signage provided was not clear, accurate and unambiguous.
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.
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