Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0265, written 13 Aug 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Aug 2018 |
|---|---|
| Reference | 2018-0265 |
| Deceased | Kamal Al-Hirsi |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Kamal Yahyia AL-HIRSI (died 10.10.17)
THIS REPORT IS BEING SENT TO:
1. Mr Justin Musgrove
Chief Executive Officer
Bannatyne Group
Bannatyne Head Office
Power House
Haughton Road
Darlington
DL1 1ST
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 16 October 2017, I commenced an investigation into the death of
Kamal Al-Hirsi. The investigation concluded at the end of the inquest on
9 August 2018. The jury made a narrative determination, which I attach.
The medical cause of death recorded was:
1a acute cardiac arrhythmia
1b cocaine and alcohol toxicity and fatty liver disease
4
CIRCUMSTANCES OF THE DEATH
1
Mr Al-Hirsi worked as a cleaner at the Bannatyne Health Club in Maida
Vale, London. On the morning of 10 October 2017, he cleaned the
swimming pool, swam two lengths and then slipped under water to the
bottom, having suffered a cardiac arrhythmia.
By the time his situation was appreciated, resuscitation attempts were
too late to change the outcome.
The pathologist gave evidence that any person may suffer an arrhythmia
from a natural cause, but on this occasion the alcohol and cocaine (not
dose related) were probably responsible.
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. Mr Al-Hirsi cleaned the pool by diving down with a suction hose
and holding his breath. This had always been the method at
Maida Vale, because there was no pole or extension head.
Whilst this did not have an impact on Mr Al-Hirsi’s death, evidence
was heard that it was inherently dangerous.
2. No thought appeared to have been given to the fact that the
cleaner who often partnered Mr Al-Hirsi in the pool cleaning
process, standing on poolside and directing him, was a non
swimmer and not confident to enter the water even at a depth of
1.5m.
In the event, she relied on a club member to undertake the rescue.
3. Members of staff had not been given any water safety awareness
training. Some did not have a proper understanding of the ways
in which a person in difficulty in the water may present, for
example that they will not necessarily wave in distress, and that
they may sink rather than float.
Mr Al-Hirsi simply sank to the bottom of the pool.
Bannatyne’s had not trained staff in the use of pool lifesaving aids.
The cleaner who first tried to help Mr Al-Hirsi attempted to poke
him with a float, but the float did what it was meant to, it floated.
2
4. Some members of staff did not know the exact location of the
panic buttons, nor the circumstances in which they should be
pressed. The panic buttons did not sound an audible alarm
throughout the building, so anyone pressing a button would not
know if it had alerted others, and staff elsewhere (other than at
reception) would be unaware that there was an emergency.
It did not occur to the cleaner who first realised that Mr Al-Hirsi
was in difficulty to press the alarm, but even if she had, this would
not have brought other staff running to help.
5. The panic button alarm was audible by a beeping sound in
reception and a light was illuminated on a control panel there, but
this relied solely on the reactions of one individual who was not
necessarily first aid trained and, if the receptionist did call 999,
s/he would not necessarily know the nature of the emergency.
In this instance, the receptionist who called an ambulance did not
know that Mr Al-Hirsi had suffered a cardiac arrest.
6. The protocol in place was that, on hearing an alarm, the
receptionist should simply contact the duty manager (who was the
designated site first aider): first by radio; failing that by sending
someone to find him; and failing that by ringing the duty manager’s
mobile phone. The receptionist gave evidence that the radios
often didn’t work, though the regional manager disagreed.
When the receptionist was notified that there was an emergency,
she could not use the radio because the duty manager had not
picked a radio up; she was unsure where he was; and when she
rang him on his mobile, she did not get through because there is
a poor reception in the plant room where he was working.
7. There seemed a lack of meaningful awareness of the defibrillator
location and function.
The first person trained in CPR (cardiopulmonary resuscitation) to
respond to the calls for help was a freelance personal trainer who
was not a member of Bannatyne staff. Although he was trained,
he did not take the defibrillator (there was only one and it was
located in the gym) with him, because at that stage he did not
know that Mr Al-Hirsi had suffered a cardiac arrest.
Some staff members had not received defibrillator training. When
the personal trainer reached Mr Al-Hirsi and realised the exact
nature of the emergency, the only other person on poolside at that
point who seemed confident of the location of the defibrillator, was
a club member who happened to be a retired doctor.
3
8. The pool was not under continuous supervision and there was no
legal requirement for a lifeguard, but it was under CCTV
surveillance. However, the camera was placed at in such a
position that it could not detect what was happening under water,
and there was a blind spot in that part of the pool nearest the
camera. After Mr Al-Hirsi slipped under water, he was completely
invisible to the camera.
9. The CCTV monitor was in reception. This was meant to be
observed every 15 minutes (to ensure maximum bather load had
not been exceeded, rather than to look for bathers in distress), but
these observations had fallen out of practice, and the monitor was
behind the head of the receptionist, so it was never in her normal
field of view. She had to turn her back on the public to look at it.
10. The written procedures did not detail the action that should be
taken on noting a bather in difficulty; they talked about RLSS
(Royal Life Saving Society) techniques being used but these were
never taught; and the duty manager at the time gave evidence
that he did not ever remember reading the standard operating
procedures or emergency action plan.
Of particular concern to me is that, ten months following Mr Al-Hirsi’s
death, many of these practices remain entirely unchanged. For example,
evidence was heard that no thought has been given to obtaining another
camera; no thought to moving the CCTV monitor; and no thought to
giving the staff water safety awareness training.
Some refresher training is being given, but this was only started two
weeks before the inquest began on Monday, and still no consideration
has been given to including the freelance personal trainer (whose
response to Mr Al-Hirsi was immediate and effective) in training
regarding health and safety procedures within the club.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you 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 8 October 2010. I, the coroner, may extend the
period.
4
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 following.
HHJ Mark Lucraft QC, the Chief Coroner of England & Wales
Camden Council, Environmental Health Department
Swim England
, brother of Kamal Al-Hirsi
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 Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
9
DATE SIGNED BY SENIOR CORONER
13.08.18
5
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.
1. -Hirsi e pool by di down with a suction hose ani Prior to the incident, the Board of Directors of Bannatyne Fitness Limited (‘the Company”) were unaware that the pool at Maida Vale had been cleaned in this unauthorised manner. Steps have now been taken across all of the Company's sites to ensure that pools are not cleaned using this method. It is understood however that this was an isolated occurrence and not commonplace in the Company's other sites. For the record however, the Company wishes to state that the evidence given at the inquest did not show, certainly to the Company's satisfaction, that this method of cleaning, whilst not acceptable, was “inherently dangerous”. indeed the pool had been cleaned at Maida Vale in this way for a number of years without incident, and as the evidence confirmed, it played no part whatsoever in Mr Al Hirsi’s death. 1.5m. In the event, she reliod © ona club member to undertake the rescue, The Company has clarified and reissued instructions to all of its Clubs to reaffirm that no employee is to enter the water for purposes of cleaning the floor of the swimming pool. The Company has updated its recruitment processes and introduced a new question on it's CV Supplement Application Form in order to determine the swimming competency of its new employees, which can then be utilised when allocating responsibilities. The Company will also ascertain the swimming competency of its existing employees by 14 October 2018. It is also the Company's intention to upskill its designated first aiders to have a pool responder qualification. We will endeavour to complete this by 31 December 2018. ied to bel ; Mr Al-Hirsi atte ed | 0 DOK joke hi with 2 a oat but the float did itwas meant to, it floated. In January 2018, the Company employed two new members of staff; a Health & Safety Compliance Manager (who was previously employed by the Company's Primary Authority) and a Learning & Development Manager to improve its training and compliance. Subsequent to this, the Company procured and, in May 2018, launched a new online Learning Management System. In order to enhance its employees’ existing knowledge, all staff are currently undertaking mandatory training modules. The Company has introduced a new module on its Learning Management System on water safety awareness, which will be mandatory for all employees of the Company. The Company will ensure that all existing employees complete this by 31 October 2018. The Company also now requires all of its new and existing employees to undertake a documented Workplace Induction Checklist, where they will be given a guided tour of their site to ensure that they are aware of the location and use of the building's emergency and life saving apparatus. The Company will ensure that all existing employees complete this by 15 November 2018. Giving evidence in a Coroner's Court, and reliving the events of the day when Mr Al Hirsi died, was extremely stressful and emotional for those Company's employees who attended. This, combined with language barriers, resulted in them being confused, which meant that regrettably, their evidence did not accurately reflect the actual circumstances of their day-to-day knowledge of the Maida Vale Club. For example, Mrs Islania was originally employed as a Domestic (cleaner) at the club and it was her responsibility to clean and dust the panic buttons located around the building. As noted above, the Company requires all of its new and existing employees to undertake a documented Workplace Induction Checklist, where they will be given a guided tour of their site to ensure that they are aware of the location and use of the building’s emergency and life saving apparatus. The Company will also review its Emergency Action Procedures (“EAP”) and ensure that its employees participate in regular documented drills. The Company's new Health & Safety Compliance Manager will audit these centrally on a quarterly basis from 1 October 2018. The Company will also review its EAPs and ensure that its employees participate in more regular documented drills to cover multiple emergencies. The Company's new Health & Safety Compliance Manager will audit these centrally on a quarterly basis from 1 October 2018. The Company has reviewed and amended its EAP, procedures and notification process for emergencies at the Maida Vale Club. Receptionists have been re-trained in recognising an alarm and the immediate next steps to be taken. The panic buttons when pressed will activate an automated message, which will be audible from all member areas of the Club and will notify all staff, including the Duty Manager(s), to muster at the Club’s Reception, The Duty Manager will dispatch employees to the emergency together with the Defibrillator and the other emergency equipment. The Company's contractors will complete the installation work by 10 October 2018. It is the Company's intention to pilot this revised emergency response system at its Maida Vale and Durham health clubs. Following a review of these systems, the Company intends to roll it out across its estate. The Company has reviewed and amended its EAP, procedures and notification process for emergencies at the Maida Vale Club. As noted above, Receptionists have been re-trained in recognising an alarm and the immediate next steps to be taken. The panic buttons when pressed will activate an automated message, which will be audible from all member areas of the Club and will notify all staff, including the Duty Manager(s), to muster at the Club’s Reception. It is the Company's intention to pilot this revised emergency response system at its Maida Vale and Durham health clubs. Following a review of these systems, the Company intends to roll it out across its estate. 7. There seemed _a lack of meanin ful_ awareness of the defibri lato lon_and At the time of Kamal’s death there was signage at the Club's reception stating the whereabouts of the defibrillator. This was standard at all of the Company's sites; defibrillators were not encased or hidden away in offices, but were located in a bracket on gym floors clearly signed in prominent locations and visible to employees, members and visitors. However, following the inquest and your Regulation 28 Report, the Company has taken the decision to relocate defibrillators to sites’ reception area, where they can be readily seen and accessed by all. The Company can confirm that this has been completed across all of its sites. The Company has also reviewed its EAPs, procedures and notification processes across all of its sites. The Company has undertaken a review of its CCTV coverage of the pool at its Maida Vale Club and has commissioned the work for the repositioning of the CCTV cameras. These works will be completed by 31 October 2018 and will include additional cameras to remove the blind spot noted at the Inquest. It should be noted that the purpose of these cameras is to monitor the number of people within the poolside environment as identified in HSG179. The images from these newly positioned cameras will be available to view on the monitor at reception. for in_distress), bu se had fallen out of practice, and the itor i of the receptionist, so it was never in her normal field of Ss @) ack on the public The Company has moved the CCTV monitor at its Maida Club to a more suitable location so that the CCTV monitor is in the constant line of sight of its Receptionists. The Company has also reinstated the 15 minute CCTV checks at its Maida Vale Club, which formed part of the Company's Normal Operating Procedure and risk assessments. evidence that he did not ever remember readina th the standard operating procedures or emergency action plan The Company has removed references to RLSS techniques from the Club's documentation. This was an unfortunate error. In September 2017 the Company set up a Water Users Group consisting of representatives of the Company's general managers, regional operations managers, regional estates managers, the Company's board of directors and external stakeholders/suppliers. The Company has widened the scope of the Water Users Group’s remit and will review and update the Company's procedures in relation to this area by 31 March 2019. refre: ining is bein ven, but this was 0) started two ee! s before the Pending the outcome of the inquest, and investigations by the Metropolitan Police and the London Borough of Camden, the Company was advised not make any changes to its policies and procedures. Changes will now be implemented at both Maida Vale and across the Company where necessary, in the light of the concerns that have been raised.
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