MAYA GRACE KANTENGULE · Prevention of Future Deaths report

On 3 May 2016 I commenced an investigation into the death of MAYA GRACE KANTENGULE, AGED 7 YEARS. The investigation concluded at the end of the inquest on 27 JULY 2017. The conclusion of the inquest was MEDICAL CAUSE OF DEATH: DROWNING. CONCLUSION: ACCIDENT.

On 1 May 2016 Maya attended a swimming pool birthday party held at Waveney River Centre. Maya was unable to swim independently. Towards the end of the party, Maya was seen unresponsive at the bottom of the swimming pool. Emergency Services were called and Maya was taken to the James Paget University Hospital where she was declared dead later that day.

(1) Prior to Maya’s death in 2004, independent Contractors had drawn up the Risk Assessments and other Health and Safety documentation relating to the organisation and the use of its facilities by staff and the public. Since 2011, the Risk Assessments were updated internally. These had been deemed “suitable and correct” by South Norfolk Council. Since 2004 there had been no formal Health and Safety Training of Directors or staff at Waveney River Centre (WRC), in particular by those responsible for health and safety and by those updating, reviewing and checking health and safety documentation.
(2) Although a Risk Assessment had been completed and updated with regard to the use of the swimming pool in 2016, there was no separate Risk Assessment in place with regard to the holding of swimming pool birthday parties. It was clear from the evidence it was believed by those at WRC to be the responsibility of the person holding the birthday party who would be responsible for the safety of the guests.
(3) Although safety procedures had not been followed on the morning of the swimming pool party, such as going through safety rules with the pool hirer and signing of documentation, and in addition the CCTV (an additional measure used by WRC to check on the pool area) was known to not be working, no checks were made on the pool party by members of staff to ensure safety rules were understood and followed.
(4) There was no evidence of awareness of staff with regard to health and safety in the pool area.
(5) Since Maya’s death, the decision has been made to hold no further external pool parties. The Swimming pool is still used by the public and WRC is still involved in activities involving the public and water.
(6) Fourteen months have passed since Maya’s death and there has been no formal health and safety training of Directors and staff. It was said on behalf of WRC they are awaiting the outcome of the inquest before arranging formal health and safety training and in addition the member of staff responsible for updating and reviewing Risk Assessments has suffered with PTSD as a result of Maya’s death. There was no indication that anyone else had been considered in respect of undergoing health and safety training, such as those ultimately responsible for health and safety at WRC or any other member of staff.