Prevention of Future Deaths reports · 2017
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 report | 8 Aug 2017 |
|---|---|
| Reference | 2017-0317 |
| Deceased | Maya Kantengule |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Other related deaths · Child Death (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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
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.
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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