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Investigation and inquest
On 16 September 2013 I commenced an investigation into the death of Keenan John WALSH, aged 4 years. The investigation concluded at the end of the Inquest on Wednesday 25 May 2016. The conclusion of the Inquest was a Narrative Conclusion, details as follows:
"Keenan, a non-swimmer, died as a result of a tragic drowning accident in the 9 foot deep end of a heated swimming pool at Bicklescombe Grage, Kingsley Avenue, Ilfracombe, whilst attending a large family party.
Sometime between 17:45 hours and 18:17 hours 23 August 2013, Keenan submerged in the deep end of the pool whilst inadequately supervised in company of a permutation of 12 children jumping in and out and two adults, neither of whom were available to rescue him. The slope of the deep end was a factor. Vision was obscured by large numbers of inflatables.
Immediate attempts at resuscitation and subsequent transfer to North Devon District Hospital, then Paediatric Intensive Care Unit at Bristol Children's Hospital, failed to avert his subsequent death from Ia. Complications of near-drowning."
Circumstances of the death
See 3 above.
The published report provides this section by reference to another part of the report.
Coroner’s concerns
(1) At the time of the incident private holiday lets with swimming pools were not regulated by the Health and Safety Department of Local Authority Environmental Health, despite tourism being a significant part of local economy. See recording of evidence of ████████ Environmental Health Officer (North Devon Council).
(2) Although there was a limited amount of signage the profile of the swimming pool fell outside accepted standards and presented a significant hazard to non-swimmers approaching a sharp slope to the deep end.
(3) The ratio of competent adults to children was one adult to anything up to 12 children at the time of this incident. This ratio was against the advice of the proprietors but unenforceable. Responsibility lay with adult family members.
