Source · Prevention of Future Deaths

Kellie Poole

Ref: 2023-0364 Date: 4 Oct 2023 Coroner: Peter Nieto Area: Derby and Derbyshire Responses identified: 1 / 1 View PDF

There is a significant lack of regulatory oversight and clear safety guidance for cold water immersion businesses, leading to inadequate risk assessments, inconsistent leader training, and insufficient safety measures for participants.

Date 4 Oct 2023
56-day deadline 29 Nov 2023 est.
Responses identified 1 of 1
Other related deaths

Coroner's concerns

AI summary
There is a significant lack of regulatory oversight and clear safety guidance for cold water immersion businesses, leading to inadequate risk assessments, inconsistent leader training, and insufficient safety measures for participants.
View full coroner's concerns
I emphasise that the matters of concern do not relate specifically to the circumstances of Kellie’s death.

It appears that there is increasing public interest and participation in cold water immersion. Businesses have been established which offer led cold water immersion sessions and may offer other types of led activities such as breath work often in combination with the cold water immersion. As businesses they charge participants a fee for the sessions. It is recognised that some people may experience an adverse physiological reaction to cold water immersion, which has the potential to be life-threatening. Whilst many leisure or health focussed activities may carry risk, where these are provider led the general expectation must be that participants are informed of risks, have an expectation that reasonable safety measures are in place, and that the provider has suitable training and experience.

There seems to be very little oversight of these businesses in their provision of cold water immersion covering matters such as pre-session health advice or warnings, public liability insurance, training and experience of the session leader, first aid training and equipment, or written risk assessments. I am not aware of the issuing of specific health and safety guidance.

Some sessions take place in water tanks, but sessions are also held in open water such as rivers, lakes, and reservoirs, and therefore at locations that may in themselves pose risk. Session leaders may have undertaken some form of training, but I am not aware that the nature and quality of the training itself is regulated/quality assured.

There is no established UK member organisation for providers of cold water immersion, other than for ‘wild’ and open water swimming which is a distinct activity, and therefore no form of even voluntary self-regulation.

On my understanding the current limits of oversight of cold water immersion providers in effect means that these activities have not received guidance from the Health and Safety Executive or other appropriate bodies. My investigation indicated that local authority environmental health departments are unclear whether they should and how they might monitor and oversee these providers.

Responses

1 respondent
Health and Safety Executive Regulator / Inspectorate
28 Nov 2023 PDF
Noted

The HSE acknowledges the concerns regarding cold water immersion activities, stating that existing regulations and guidance from other organisations (RNLI, National Water Safety Forum) provide a suitable basis for businesses to operate safely. They will not be publishing specific guidance at this time but will keep the activity under review and raise awareness among local authority enforcement officers. (AI summary)

View full response
Dear Sir REGULATION 28 PREVENTION OF FUTURE DEATHS – COLD WATER IMMERSION Thank you for your Regulation 28 report to Sarah Albon, HSE Chief Executive, in relation to the death of Ms Poole while participating in a cold water immersion activity. I am responding as the Head of Local Authority and Safety Unit at the Health and Safety Executive (HSE) which holds the operational policy lead for health and safety regulation of the leisure sector. Your report raises as matters of concern, that cold water immersion providers have not received guidance from HSE or other appropriate bodies and that local authority environmental health departments are unclear whether they should and how they might monitor and oversee these providers. Providers of cold water immersion services to the public are required to comply with the Health and Safety at Work etc. Act 1974 and the Management of Health and Safety at Work Regulations 1999. This legislation provides a framework for securing health, safety and welfare by requiring businesses providing cold water immersion services to identify risks to their workers and customers from their activities and to take action by putting in place suitable measures to manage those risks. Businesses are also required to appoint a competent person(s) with the skills, knowledge and experience to recognise hazards and to assist with putting into place effective measures to protect workers and others from harm. There is no legal requirement for businesses to hold public liability insurance or to make first aid arrangements for customers. HSE does, however, strongly recommend that non-employees are included in assessments of first aid needs and that provision is made for them. When assessing and managing risk, businesses should take account of relevant guidance. To help businesses comply with the law, HSE provides general guidance on health and safety such as HSE’s health and safety basics for your business (https://www.hse.gov.uk/simple-health-safety/index.htm) as

well as targeted guidance for higher-risk industries and activities. HSE does not seek to provide guidance for all industries and activities as it is often the case that others are more knowledgeable or better placed to provide such guidance. The risks associated with open water and cold water shock are well known and relevant guidance is available from multiple authoritative sources such as the RNLI (https://rnli.org/safety/know-the­ risks/cold-water-shock) and the National Water Safety Forum (https://www.nationalwatersafety.org.uk/adviceresources/open-water-swimming). In addition, guidance is also widely available from local authorities and the emergency services such as that provided by Staffordshire Moorlands District Council (https://www.staffsmoorlands.gov.uk/article/6759/Safety- around-open-water) and Staffordshire Fire and Rescue Service (https://www.staffordshirefire.gov.uk/your-safety/safety-outside/water-safety/). It is HSE’s view that the regulatory provisions in place requiring cold water immersion providers to manage risks, together with the guidance available from multiple sources on the main risks involved, provide a suitable basis for businesses to provide activities safely and for local authorities to take regulatory action where required. Consequently, HSE will not be publishing specific guidance at this time for cold water immersion activities. However, as this is a newly emerging leisure pursuit we will keep this activity under review. HSE will continue to support and liaise with our regulatory partners in local authorities who are predominantly responsible for the enforcement of work related health and safety legislation in this area. To increase awareness among local authority enforcement officers I have asked that this matter is raised at the national Local Authority Health and Safety Practitioner Forum (https://www.hse.gov.uk/lau/national-committees.htm). I hope that the above information addresses the matters raised.

Report sections

Investigation and inquest
On 28 April 2022 I commenced an investigation into the death of Kellie Jean POOLE aged 39. The investigation concluded at the end of the inquest on 27 September 2023.
Circumstances of the death
Kellie died on 25 April 2022 on the river bank of the River Goyt near to Whaley Bridge in Derbyshire. She had collapsed in the river whilst participating in a led session of cold water immersion. On the evidence it is likely that the cold water triggered her heart to go out of rhythm which then led to her sudden cardiac death.

On post mortem examination it was identified that Kelly had an abnormal heart, although she had never been diagnosed with or suspected to have a heart condition. It is likely the heart condition prevented recovery from the heart dysrhythmia.
Copies sent to
(Principal Environmental Health Officer Staffordshire Moorlands District Council/High Peak Borough Council)

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Report details

Reference
2023-0364
Date of report
4 October 2023
Coroner
Peter Nieto
Coroner area
Derby and Derbyshire

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 29 Nov 2023 (estimated).

Sent to

Health and Safety Executive

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