Prevention of Future Deaths reports · 2017

Maya Kantengule

Regulation 28 report to prevent future deaths, reference 2017-0317, written 8 Aug 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report8 Aug 2017
Reference2017-0317
DeceasedMaya Kantengule
CoronerJacqueline Lake
Coroner areaNorfolk
CategoryOther related deaths · Child Death (from 2015)
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

1. MR JAMES KNIGHT
DIRECTOR
WAVENEY RIVER CENTRE
STAITHE ROAD
BURGH ST PETER
NORFOLK
NR34 0BT

1 | CORONER

| am JACQUELINE LAKE, senior coroner, for the coroner area of NORFOLK

2 | CORONER’S LEGAL POWERS

| 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 3 May 2016 ! 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.

4 | CIRCUMSTANCES OF THE DEATH

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.

5 | 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) Prior to Maya’s death in 2004, independent Contractors had drawn up the Risk
Assessmenis 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.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe your
organisation has the power to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 3" October 2017. |, 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.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:-

Local Safeguarding Board
South Norfolk Council

lam 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.

DATE & Pye ev), SIGNED BY CORONER Ohte

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 Waveney River Centre (PDF)
Your ref
Our ref

8/DFM/W5688-827684 (DFM) Kennedys

25 Fenchurch Avenue
London
EC3M 5AD

United Kingdom |
The Coroner T +44 20 7667 9667
Norfotk Coroner's Court F +44 20 7667 9777
Eastgate House DX 766 London City

122a Thorpe Road on kanmodysiaw.com
Norwich . sretiligenncncsmrperninan eae

Direct Dial
T [+44 20 7667 9206

Email

NR1 RT

danny.mcshee@kennedyslaw.co

m
Date

06 September 2017

Dear Sir/Madam

RESPONSE TO REGULATION 28: REPORT - WAVENEY RIVER CENTRE

The evidence from South Norfolk Council was that the management of the swimming

pools has one of the most prescriptive Health and Safety Guidance documents produced

by the Health and Safety Executive. The Council accepted that for a pool of this size
and depth with its features, there would be no need to continuously supervise the pool.
This is the reason why swimming pools in hotels and swimming pools in leisure centres
for example routinely de not have lifeguards.

The Council accepted that this remains their view today and a detailed review by one
of the leading consultants following the sad incident involving Maya confirmed that the
pool would not require continuous supervision by way of lifeguarding, or in any other
way.

The evidence was that the Centre would on occasion privately hire its pool to people
that wanted to hire it for swimming pool parties. The evidence of the hirer on this
occasion was that she knew in advance that there would be no lifeguard. The evidence
given by WRC cenfirmed that she was also told this in advance. This was not challenged
by the hirer who said that she could not remember. There was also a very prominent
sign on the entrance to the pool making it clear that there was no lifeguard.

The evidence was therefore absolutely clear that the hirer on this occasion knew that
there was no lifeguard and was responsible for the supervision of the children attending

her child’s party.

Kennedys is a trading name of Kennedys Law LLP.
Kennedys Law LLP is a limited liability partnership registered in England and Wales (with registered number 0C353214).

Kennedys offices, associations and cooperations: Australia, Argentina, Belgium, Brazil, Chile, China, Colombia, Denmark, England and
Wales, France, Hong Kong, india, Ireland, Italy, Mexico, New Zealand, Northern Ireland, Norway, Pakistan, Peru, Poland, Portugal, Russian
Federation, Scotland, Singapore, Spain, Sweden, United Arab Emirates, United States of America.

A list of members’ names is available for inspection at our registered office at 25 Fenchurch Avenue, London EC3M SAD, Kennedys Law LLP is
‘authorised and regulated by the Solicitors Regulation Authority. We use the word ‘Partner’ to refer to a member of Kennedys Law LLP, or an

employee or consultant who is a lawyer with equivalent standing and quatifications.

Legal\22317331.1

The C Va ly
Norfolk Coroners Court Ken nedys

Her evidence was that there had been no discussion with parents as to the swimming
ability of their children and that she had undertaken supervision with other parents
from an observation area overlooking the pool. However, she also confirmed that she
had left this area on a number of occasions, including to go into the changing rooms.
She accepted that there were no discussions with other parents to ask them to take on
the responsibility of supervision in this period and also confirmed that at the time Maya
was found she did not think that there was any adult in the observation area adjacent
to the deeper end of the pool where Maya was found.

It therefore gives a misleading impression of the evidence in the Regulation 28 Report
to state “It was clear from the evidence it was believed by those at WRC to be the
responsibility of the person holding the party who would be responsible for the safety
of the guests.” This was the evidence of the private hirer as well.

As the report does state, independent contractors had drawn up the Risk Assessments
and other health and safety documentation relating to WRC and use of its facilities by
staff and the public, specifically the regime for the use of the swimming pool was
established by those consultants. The risk assessment, the Consultants created,
included a specific question asking whether there is any equipment or activities to
generate excitement. As stated, South Norfolk Council accept that this pool does not
require continued supervision and the only issue between them and the Centre is
whether or not a separate Risk Assessment. should have been undertaken for swimming
pool parties. This is against the background that in 2011 Sauth Norfolk Council wrote
to WRC to state that it believed its Risk Assessment for the pool was suitable and
sufficient. In addition, there is no certainty, as South Norfolk Council fairly
acknowledged when giving evidence that a separate risk assessment would have led to
the pool being lifeguarded during parties.

A decision was made following this sad incident that the Centre would no longer
privately hire its pool for swimming pool parties and the relevant risk therefore that is
‘said may have caused Maya’s death no longer exists.

In terms of wider training, the independent safety consultants who had worked closely
with the company over many years had provided many hours of mentoring and on the
job training and assistance to the Managing Director of the Centre and another member
of his staff. Whilst it is correct that they had not undertaken formal training, the only
evidence on this subject was from the Managing Director of WRC. He gave evidence
that mentoring was focused and the Centre has been run with an excellent safety record
for 14 years. The evidence was that the Centre takes safety extremely seriously. There
was no evidence that any other aspect of WRC’s safety management may be
insufficient.

The Managing Director made it clear in his evidence that this incident had caused him
to think that further training would be prudent and that there was an intention by the
Centre to send staff onto formal safety training courses such as OSH. His evidence was
that this would be taken forward once the inquest had concluded. That remains the
case and WRC’s response to this notice is that such formal training has already been

Legal\22317331.4 2of3

Norfolk Coroner's Court Kennedys

arranged, as was the Company’s intention. However, WRC is very sensitive to any
suggestion that its management of safety generally was deficient as there was no
exploration of its systems at the inquest beyond the management of its swimming pool.
In relation to that, as stated, WRC no longer hold pool parties and the accepted
evidence of South Norfolk Council is that its pool does not require continuous
supervision for its general use.

Yours faithfully

Kennedys

Legat\22347334.1 3 of 3

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