Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0243, written 29 May 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 May 2014 |
|---|---|
| Reference | 2014-0243 |
| Deceased | Loui Aspinall |
| Coroner | Alan Walsh |
| Coroner area | Manchester (West) |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive, Federation of British Tour Operators, 30 Park Street, London, SE1 0EQ 1 | CORONER T am Alan Peter Walsh, Area Coroner, for the Coroner Area of Manchester West |2 | CORONER'S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 | INVESTIGATION and INQUEST On 30" September 2013 I commenced an investigation into the death of Loui Aspinall, 2 Years, born 7 November 2010. The investigation concluded at the end of the inquest on 14" May 2014. The Medical cause of death was 1a Drowning. The conclusion of the inquest was Accident. 4 | CIRCUMSTANCES OF THE DEATH 1. Loui Aspinall died at the Houda Golf and Beach Resort, Skanes, Tunisia on the 25" September 2013. 2. On the 22™ September 2013 the deceased went on holiday with his mother, father and sister to stay for a period of two weeks at the Houda Golf and Beach Resort, Skanes, Tunisia. 3. The Houda Golf and Beach Resort has a large swimming pool with access into the swimming pool by walking into shallow water with a gradual slope increasing the depth of the water into the swimming pool. At one end of the swimming pool there is a bridge over the pool and on the day of Loui’s death there was a sign either on the bridge or near to the bridge which stated that there were no lifequards on duty at the pool. However, evidence was heard at the Inquest that each day one lifeguard was seen to be present around the swimming pool area. 4. At or about 13:12 hours on the 25" September 2013 CCTV cameras revealed that Loui Aspinall walked into the swimming pool on his own and he became submerged by the water in the swimming pool as he continued to walk towards the centre of the swimming pool. He was not seen to enter the swimming pool by any witnesses but approximately seven minutes later at 13:18.48 hours he was seen, by two children, to be under the water in the swimming pool and he was rescued by a tourist at the hotel at 13:19.28 hours. Loui was lifted out of the swimming pool by the tourist at 13:19.35 hours and, in spite of attempts at resuscitation, he died. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: 1. During the inquest evidence was heard that: i, The tour operator arranging the holiday for the Aspinall family was TUI UK Limited and in order to achieve a consistent health and safety level across hotels, tour operators in the United Kingdom, including TUI UK Limited, have adopted a risk management approach which involves undertaking a programme of audits of their suppliers. The audit questions reflect industry standards, which are suggested within the Federation of British Tour Operators Guidelines. The guidelines are drawn up in collaboration with UK Industry Health and Safety specialists and in consultation with ABTA/Federation Tour Operator members. The Federation of British Tour Operators also issue a suggested Tour Operator audit checklist which covers all general safety issues and upon which the content of audits undertaken by TUI UK Limited are based. ii. On the 1% May 2006 TUI UK Limited entered into an agreement with Argent Health and Safety whereby the auditing process was contracted out to that company. Argent Health and Safety is an independent specialist Health and Safety consultancy who provide specialist advice and auditing services to TUI UK Limited and other UK Tour Operators. iii. Argent Health and Safety carried out Health and Safety audits at the Houda Golf and Beach Resort, Skanes on 20" July 2011 and the 22" March 2013 using an Audit Checklist based upon the Federation of British Tour Operator Guidelines. The audit indicated that there was a trained dedicated lifequard on duty at all times when the swimming pool was open and that there was adequate and prominently displayed rescue equipment around the pool. iv. The evidence at the inquest was that there was no obvious N 2. resuscitation equipment or rescue equipment around the | swimming pool at the Houda Golf and Beach Resort. Furthermore the sign at the swimming pool indicates that lifeguards were not on duty at the swimming pool, although a lifeguard was seen each day. However when Loui Aspinall was rescued from the pool a lifeguard, who attended did not appear to have First Aid knowledge in relation to the resuscitation of a child. v. On the Audit Checklist used by Argent Health and Safety in relation to the audit at the Houda Golf and Beach Resort on the 22"4 March 2013 referred to three questions under the heading Lifeguard Supervision and Rescue, namely :- On audit the response to each of the above questions was yes, The evidence at the inquest was that, even though the above questions featured on the audit list, there was no requirement for them to be present within the best practice guidelines issued by the Federation of British Tour Operators. The evidence was that there was no requirement for lifeguards at a swimming pool unless the swimming pool fell within Regulations relating to Waterparks. I have concerns with regards to the following :- a. Does the pool have a trained dedicated lifequard on duty when the pool is open? b. Is a member of staff trained in first aid on duty at all times when the pool is open? c. If resuscitation equipment is available, is there a member of staff trained in its use when the pool is open? Best practice guidelines issued by the Federation of British Tour Operators do not appear to include a requirement for the presence of a lifeguard at a swimming pool trained in first aid and the provisions of resuscitation equipment and rescue equipment in obvious and designated areas around a swimming pool. British tourists will have an expectation that trained lifeguards, resuscitation equipment and rescue equipment are present at swimming pools, particularly at family hotels, both in the United Kingdom and in foreign countries. The best practice guidelines issued by the Federation of British Tour Operators do not refer to emergency procedures at hotels and resorts. The availability of emergency procedures and emergency equipment at hotels and resorts are necessary to reduce a risk that future deaths will occur unless action is taken, 3. Trequest the Federation of British Tour Operators to consider the above concerns and to review the best practice guidelines issued to Tour Operators, particular with regard to :- i. The presence of lifeguards trained in first aid at swimming pools, particularly in family hotels and resorts in the United Kingdom and Foreign Countries. ii. Resuscitation equipment and rescue equipment in obvious and designated areas around swimming pools particularly in family hotels in the resorts in the United Kingdom and Foreign Countries. iii. The existence of emergency procedures and emergency systems to deal with incidents in and around swimming pools, particularly in family hotels in the resorts in the United Kingdom and Foreign Countries. 6 | ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 24th July 2014. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Perso A oui Aspinall’s father and to the LOCAL SAFEGUARDING BOARD.I have also sent it to Minister of State for Culture, Media and Sport who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 | Dated Signed = 29" May 2014 Alan P Walsh
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