Jane Bell

Date of report	22 Mar 2016
Reference	2016-0119
Deceased	Jane Bell
Coroner	Alan Wilson
Coroner area	Blackpool and Fylde
Category	Other related deaths
Source	judiciary.uk record · original PDF
Responses published	1

The report

Text extracted from the PDF text layer. 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: 

Managing Director 
The Dalmeny Hotel 
19 – 33 South Promenade 
Lytham St. Anne’s 
Lancashire 
FY8 1LX 

1 

CORONER 

I am Alan Wilson, Senior Coroner, for the area of Blackpool & Fylde 

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 

The medical cause of death was recorded as follows: 

1 a Drowning 

The conclusion was that “Jane Bell died as a result of an accident”.  

.                 

4 

CIRCUMSTANCES OF THE DEATH 

In box 3 of the Record of Inquest the following was recorded: 

“Jane Bell died in the Paediatric intensive care unit at Manchester Children’s Hospital at 
19.55 on 14th August 2014 as a result of drowning caused by a deliberate human act 
which has unexpectedly and unintentionally taken a turn that leads to death. Inadequate 
staff training and pool supervision are considered contributing factors”.  

In more detail the circumstances were: 

  This incident that was captured on the hotel CCTV system. Jane Bell was being 

supported by her Mother in the deep end of the hotel pool when she went under 

the water where she remained for almost two minutes until a hotel guest dived 

into the water and rescued her. She was revived initially, taken to hospital but 

later passed away. At the time she was wearing no arm bands although these 

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                       
 
 
 
 
 
                
 
   At the time of the incident there was no constant pool side supervision by hotel 

staff.   

  There was some signage in the pool area which included advice for swimmers 

including information about the pool depth and that only competent swimmers 

should go beyond a certain point in the pool but the inquest heard from one 

witness that because she felt that her Great Nephew, aged 10, was what she 

regarded as a strong swimmer she didn’t pay much notice to the signs.   

  The inquest heard how before the child was rescued from the water by a hotel 

guest, a member of the leisure staff who had been working on the reception 

desk had dived into the water but was unable to retrieve the child from the pool 

floor, although at that time she had not received pool response training that 

may have assisted her in rescuing a casualty from the bottom of the pool [which 

she has subsequently received].  

  Staff who worked on the reception desk were expected to monitor activity in the 

pool by way of CCTV footage. On the morning of the incident a member of staff 

spent at least 90 minutes working alone in reception and given the other duties 

he was expected to carry out he was unable to constantly view the pool area by 

way of the CCTV monitor and during that period there were no staff pool side in 

the pool area.  

  Another hotel guest explained in a statement that he and his young family had 

made use of the hotel leisure facilities previously, had noted the leisure club 

staff around the pool side areas, and specifically recalled leisure staff being 

visible and blowing their whistles to attract the attention of swimmers during 

what he described as “float time”. He was conscious of the need for children to 

wear armbands, said that there is a clear divide from the shallow to the deep 

end; that anyone beyond that divide would have to be a strong swimmer to look 

after a 3 year old child 

  A Leisure Manager confirmed that staff has received 1st Aid and pool response 

training in November 2014 but not at the time of this incident. The training 

involved entering the water to assist a casualty, and had included simulation 

using a “dummy”, and a monthly refresher.  

  The inquest heard that although there is safety equipment available, whilst this 

could assist in aiding someone struggling at the surface it would not help 

someone on the bottom of the pool.  

  Staff will now patrol the pool side area at least hourly and when the numbers of 

2

 
   A Managing Director at the hotel said that since this incident the hotel had 

conducted a comprehensive review of policies and procedures in respect of 

health & safety and that as regards the issue of constant poolside supervision 

she explained that both the previous and the current consultants were of the 

view that although the industry guidance requires constant pool side supervision 

for this type of pool, but that this can be provided by way of a combination of 

factors including pool side checks and CCTV monitoring of the pool area. All 

members of leisure and entertainment staff have now been provided with 

poolside response training but that in the event of a pool emergency she would 

expect it to be one of two people in reception who respond and attend.   

  She confirmed that the hotel – in response to a report seen in January 2016 – 

propose to have work carried out this summer to make the pool shallower.  

  She told the inquest that the hotel may not be able to continue to operate the 

pool facility if a constant lifeguard were to be needed, and a later expert 

witness explained how lifeguards are allowed to work for an hour but then need 

20 or 30 minutes off and so more than the one lifeguard would need to be 

employed. The hotel has approximately 33,000 guests annually and this incident 

was the first such incident at the hotel, and a Fylde Borough Council employee 

confirmed no previous issues had been raised by the Council with the hotel as 

regards the pool facility at the Dalmeny Hotel.  

  A Health & Safety expert witness said a pool operator such as the Dalmeny 

Hotel has three options available to it to reduce the risk of drowning in the 

swimming pool to an acceptable level. These were to provide a lifeguard, or 

alternatively to remove the hazard by changing the design to remove the deep 

water, or to increase control measures to include a reliable drowning detection 

system, qualified rescue staff, improved signs, training against a revised Normal 

Operating Procedure and ensuring patrols of the area every few minutes with 

improved CCTV. He said that pool side patrols in his opinion ought to be 

undertaken every five minutes and that he personally was not a fan of CCTV 

and that if CCTV is at times to be the primary source of checking the pool this 

was not in his view sufficient given the depth of the pool and because staff can 

be distracted.    

5 

CORONER’S CONCERNS 

3

                    
 
 
 
 
 
 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: 

I am concerned that the arrangements which the inquest was told are currently in place 

at the hotel are such that there remains a risk of future deaths. 

Although the inquest heard expert evidence to the effect that the requirement that there 

be constant poolside supervision can be met by a combination of other factors notably 

poolside patrols and CCTV monitoring and that the hotel aims to provide this, I am 

concerned that the way in which this is to be delivered is insufficient and the duty to write 

this report is satisfied. 

There are now two members of staff employed in the reception area at all times when 

the pool is open to swimmers. However, although the proposed pool side patrols are to 

be undertaken at certain parts of the day at 15 minute intervals, at other times when the 

number of swimmers in the pool is lower these patrols may take place less often and up 

to a minimum of once per hour. 

The inquest heard that on the day that Jane Bell died a Leisure Assistant was unable to 

constantly monitor the pool by way of the CCTV screen / monitor in reception because 

he was at that time trying to also perform other tasks such as booking guests into the 

gym, distributing towels etc. The hotel – as confirmed by the Managing Director at the 

inquest – takes the view that because two staff will now be based in reception that this 

will ensure those tasks can be performed whilst the other member of staff monitors the 

pool thereby ensuring constant supervision. I do not find this argument convincing to the 

extent I am satisfied the duty upon me to write this report is not met. The expert witness 

told the inquest that he was “not a big fan” of CCTV, and it appears to me that even with 

two members of staff in the reception area, and given the other tasks such staff have to 

deal with, it is unlikely that between them the two members of staff will always have the 

pool in their sight at all times.  

4

 
 
 
 
 
 
 This is concerning when considered in combination with the proposed pool side patrols. 

If it was envisaged that such patrols be undertaken at 5 minute intervals throughout 

times when children may be swimming in the pool, a few moments during which the 

reception staff may be distracted and dealing with other tasks and not observing the 

CCTV footage may be less of a concern because a member of staff undertaking patrols 

at 5 minute intervals would have the chance to observe families, assess if they are 

complying with the rules set out on signs within the pool area, and recognise whether 

swimmers who need floatation devices such as arm bands are indeed using them.  

However, if such patrols take place less frequently the chances of the staff performing 

those patrols identifying issues that may place a child swimmer at risk are diluted. This 

appears to be a concern even if the hotel does facilitate patrols at 15 minute intervals as 

they propose at all times during which the pool is occupied by families. At present, a 

family may enter the pool and be swimming in the pool for some time, and maybe up to 

an hour, before being observed by a member of staff patrolling the pool area should that 

family chose to use the pool at a time of low occupancy. This may not be a problem if 

they area family who are not safety conscious, are unaware that there is no constant 

pool side presence, have over-estimated their child’s swimming ability and paid 

insufficient attention to the pool signage as a result, are not complying with the hotel 

regulations for whatever reason. A problem then arises if that family is allowing a child to 

swim alone or in the deeper half of the pool or without floatation aids when they need 

one.  

Jane Bell was under the water for slightly less than two minutes and this proved fatal. I 

am concerned that reception desk staff may be distracted for a similar time leaving them 

unable – in spite of the encouraging work that has been undertaken since this fatality to 

train leisure and entertainment staff in first aid and pool side rescue which the expert 

witness felt ought to enable staff to effect a pool rescue – to rescue a child and prevent 

a similar fatality. The time needed to assist a child under the water is limited and 

5

 
 
 
 
 poolside safety equipment at the hotel is limited to devices that may be used to assist 

someone struggling on the surface but not necessarily a child under the water. 

The impression given during evidence at the inquest was that the hotel management 

felt that there is a marked difference between time of high pool occupancy and other 

times when the use of the pool is much less. The concern about future deaths does not 

arise in respect of times when the pool is empty or when only adults are using it. The 

concern arises when perhaps only one or two families are using the pool. The evidence 

provided at the inquest suggested that at such times, pool side patrols would take place 

much less often that at fifteen minute intervals and I am concerned that more 

infrequent patrols – when families are using the pool – would not satisfy the 

requirement for constant supervision. Indeed as the expert witness stated at the 

inquest, he was of the opinion that such patrols ought to be conducted at five minute 

intervals. 

At the conclusion of the inquest, I indicated to the Properly Interested Persons that I 
proposed to write to the Trust by way of a report in accordance with the provisions of 
paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009. 

6 

ACTION SHOULD BE TAKEN 

In my opinion 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 18th May 2016. 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 
Persons: 

  The family of Jane Bell 
  Chief Executive of Fylde Borough Council 
  Chief Executive of Blackpool Council 
  Chief Coroner of England & Wales 

6

  
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 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 

A.A.Wilson 

Alan Wilson 
Senior Coroner for Blackpool & The Fylde 
Dated: 22nd March 2016  

7

Responses

1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Respondent Not Named (PDF)

dalm eny A great British seaside

RESORT HOTEL

HM Coroner
Blackpool and Fylde
Coroner’s Office
Municipal Buildings
PO Box 1066
Corporation Street
Blackpool

FY11GB

5" May 2016

Dear Sirs

RE: JANE BELL DECEASED
INQUEST ON 147 MARCH 2016 - REGULATION 28 REPORT
Ove matter we can confirm that we received the Regulation 28 Report dated

Further to the ab
22°° March 2016.

At the inquest |, Samantha Lewis on behalf of the Dalmeny Hotel Confirmed that all members
of the leisure staff which includes those based primarily on reception, have poolside
responder training. This would enable a member of staff to appropriately deal with an
incident in the Pool, including diving to the bottom of the pool at its depth of 2.44m to effect a
rescue.

Since the inquest the Hotel has had constant poolside supervision in place at all times when
the pool is Open regardless of whether itis in use. This involves one member of staff (with
Poolside responder training) constantly Patrolling at the Poolside and another member of
Staff (also poolside responder trained) continually monitoring the CCTV footage from the

reception desk.

The member of staff at Poolside is refreshed at half hourly intervals. The swap is done at
Poolside to maintain the constant Supervision.

All staff have been trained in the role of poolside Patrols and what the Monitoring entails.
This involves keeping a head Count of bathers to ensure that there is not overcrowding within
the pool. Every 30 minutes the poolside Patroller radios to reception with the head count.

Large Hotel

dalmen y A great British seaside

RESORT HOTEL

= — Ss , exe

This head count is recorded. Behaviour is also monitored and anybody acting
inappropriately or not following the pool rules, for example diving, is asked to desist or leave
the pool. In the event of an incident occurring within the pool there is a member of staff
present who can deal with it appropriately and in line with the training they have received.
Alcohol and food are not and never have been permitted to be consumed within the pool.
Further they cannot be taken into the leisure area due to the layout.

In addition to this there are documented pool hall safety checks and inspections carried out
On opening and closing. These inspections consist of checking the water rescue equipment,
looking at the water clarity and lighting and signage and also require the communication

There is a daily alarm check in place which requires the activation of all of the emergency
alarms within the department.

As of 3% May 2016 the pool has been emptied and closed for its depth to be reduced to
1.4m at its deepest end with no abrupt changes to depth. The pool will re-open on 27" May
2016 at the reduced depth.

All signage is to be changed around the poolside and notification will be given that the Hotel
does i i

followed.

All members will also be Provided with a further induction covering the fire escapes, raising
alarms and pool safety.

There is a Health Commitment Statement which all leisure members and hotel guests have
been asked to sign and which requests that they do not exercise beyond their capabilities
and that all swimmers bathe at their own risk.

The pool rules such as no diving will be reinforced to swimmers as they check into the
leisure centre.

The requirement for constant supervision under HSG79 will cease once the depth of the pool
is reduced as none of the other criteria within the guidance applies. However, the CCTV will

All members of staff will continue to receive refresher training on poolside responder.

In addition to this the Hotel has appointed Adrian Thomas as a new Leisure and Spa
Operations Manager. He has held various industry related qualifications as follows:

FY8 1LX
co.uk

| Winner —_|

Large Hotel

dalmen ¥ A great British seaside

RESORT HOTEL

cea SSS

° Royal Life Saving Society (RLSS) Pool Lifeguard
e NARS (National Rescue Standard)

e Personal Trainer

e Fitness Instructor

e Exercise to Music Instructor

e STA Poo! Plant Level III

Mr Thomas has been in the leisure industry since 1994 and has previously worked for
Holiday Inn at Kew Gardens and other hotel chains managing their leisure facilities and in
particular their swimming pools.

We trust that this alleviates your concerns and responds to the recommendations raised in
your report.

The Dalmeny Hotel takes the health, safety and welfare of its employees, guests and
members extremely seriously and since this terrible incident has acted Promptly and
comprehensively. The Hotel has reviewed its systems and procedures and put in place
steps and measures to reassure the Local Authority and the Coroner that there is unlikely to
be any recurrence of such an incident again or anything similar.

that has taken Proactive initiatives to try to ensure the Safety of its workforce in an
industry that carries with it a wide variety of inherent risks.

—_

Tegan

Large Hotel

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