Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0317, written 24 Oct 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Oct 2018 |
|---|---|
| Reference | 2018-0317 |
| Deceased | Catherine Gibbon |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Catherine Mary GIBBON (died 02.06.18)
THIS REPORT IS BEING SENT TO:
1. Mr Martin Long
Chief Executive Officer
DW Fitness First
Whelco Place
Enfield Street Industrial Estate
Wigan WN5 8DB
2. Mr Steven Ward
Chief Executive Officer
UK Active
4th & 5th Floor
26-28 Bedford Row
London WC1R 4HE
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 11 June 2018, I commenced an investigation into the death of
Catherine Mary Gibbon, aged 44 years. The investigation concluded at
the end of the inquest on 11 October 2018. At inquest, the jury made a
narrative determination, which I attach. The medical cause of death was
recorded as:
1a hypoxic ischaemic brain injury
1b non fatal drowning
1c epilepsy
1
4
CIRCUMSTANCES OF THE DEATH
Catherine Gibbon was swimming in the pool at the Tottenham Court
Road branch of Fitness First on Friday, 1 June 2018, when she suffered
a seizure.
She floated head down in the water for around ten minutes before she
was seen by another gym member. During this period of oxygen
deprivation she sustained a brain injury that resulted in her death.
Early detection and prompt, appropriate first aid would probably have
saved her life.
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. When Ms Gibbon joined the gym, she was given a health pledge
to read. In this, she agreed to inform a member of staff if she had
a medical condition that might interfere with exercise. However,
she was not given any assistance in understanding which medical
conditions would come in to this category. Even the staff taking
her through the health pledge did not have a clear understanding
of this.
2. There was also no clear understanding across staff of what
additional help, if any, could be offered to a swimmer with
epilepsy. Any understanding seemed to concentrate upon Ms
Gibbon obtaining a doctor’s letter authorising swimming.
Whilst there is of course merit in prompting a discussion with a
potential swimmer’s doctor about the advisability of swimming,
Fitness First indicated that constant monitoring of such a swimmer
will not be offered.
3. The pool was not under continuous supervision and there was no
legal requirement for a lifeguard, but it was under CCTV
surveillance. The CCTV monitor was in reception. However, no
training or guidance was given to the gym receptionist about what
she should look for on the monitor and what she should do if all
was not as she expected.
2
Most especially, she was not given any instruction as to how
frequently to check the monitor.
4. The receptionist also gave evidence that in her opinion, the
screens (the monitor was split into four screens for the four
cameras) were too small to see the pool activity clearly.
5. In fact, one of the four cameras had been broken since 24 May.
It had not reported and no alternative measures had been taken
since it had become non operational.
Three minutes and 20 seconds after her seizure began, Ms
Gibbon floated a short distance into the field of the broken
camera. From this point, she was completely out of sight of the
CCTV monitor.
6. There was no panic button that would activate 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.
7. There was no landline at poolside that could be used to call an
ambulance in case of emergency, to enable medical assistance
to be summoned immediately by someone who actually had sight
of the casualty.
8. There was a defibrillator in the gym, but there was not another at
poolside.
9. Fitness First had made the decision that all first aid certificates
would be renewed after one year rather than the usual three, but
then the certificates were allowed to lapse because one person
made an error and there was no failsafe system.
Fitness First have taken steps to address some of these issues, and told
me that such learning is shared at a national level. However, at inquest
Fitness First national lead for health and safety told me that he was
unaware that I sent a prevention of future deaths report to Bannatyne’s
on 13 August 2018, regarding a death in similar circumstances in Maida
Vale on 10 October 2017. I did copy this report to Swim England, but
this does not appear to have prompted a national conversation among
private pool providers.
I leave that now with UK Active.
6
ACTION SHOULD BE TAKEN
3
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 24 December 2018. 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 following.
HHJ Mark Lucraft QC, the Chief Coroner of England & Wales
Camden Council, Environmental Health Department
Swim England
Sport England
, parents of Catherine Gibbon
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
24.10.18
4
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