Bannatyne Fitness Limited
Action Taken
The company has reissued instructions that employees should not enter the water to clean pools, updated recruitment processes to determine swimming competency, and removed references to RLSS techniques from club documentation. The company will review and update procedures related to this area by 31 March 2019. (AI summary)
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Response by Bannatyne Eltness_Limited to the Regulatlon 28 Prevention of Euture Deaths Report_in thematter of_Kamal AL HlrsL (date of death 10 10.1Z) MAlHirsicleaned_the_pooL bydiving_down with asuction_hose_and_holdinghis breath_This had_alwavs_been _the_method at Malda Valebecause_there was nopole or extension head_Whilst this did not have an impact on Mr AL Hirsi's death_evidence was heard thatit was inherently dangeroys 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 (hat this was an isolated occurrence and not commonplace in the Companys other sites. For the record however; the Company wishes to state that the evidence given at the inquest did not show, certainly to the Companys 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.
2. Nothought_appeared to_have_been_given _to the_fact_that_the_cleaner_who_often partnered Mr AL-Hirsiin _thepool cleaning processstanding on poolsideand directing bim_was _ anon-swimmer_and_not_confident_to enter the_water_even ata depthof L5mlntheevent_she relied on a 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 Fomm 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. 3_ Members of_staf had not been given any water safety awareness training_Some did pothave _ aproper_understandingof_the_wavs_In_which a person in dificultv_in the water_may present_for_example that_ they wlL nt necessarily wave in distress_and that_ they may sink rather_than foat_MrALHirsi simply sank to the_bottom of the pooL Bannatyne's had not trained staff_in the_use of_pooL lifesaving aids_The cleaner who Irst tried to help MrAL Hirsi attempted to poke him_with a float_but the dloat did what iwasmeanto itiloated
In January 2018, the Company employed two new members of staff; Health & Safety Compliance Manager (who was previously employed by the Company's Primary Authority) and Learning & Development Manager to improve its training and compliance. Subsequent to this, the Company procured and, in May 2018, launched 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 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.
4. Some members_of_stalf_did not know the exact location of the_panic buttons_nor the circumstances in which they should bepressed_The_panic buttons did not soundan audible alarm throughout the buildingSQ anyone pressing a button would not know if ithad alerted others_and staff elsewhere (other than at reception) would be unaware that_ there_was an emergency_Itdid not occur to the cleaner who first realised that Mc AL-Hirsi_was In difiiculty_to_press the alarm but even if_ she_had_thls would not have brought other staff nunning tohelp 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 are aware of the location and use of the building's emergency and Iife 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 October 2018. they - Giving they
5_ The_panlc _button alarm was audble bY a beeplng sound In reception anda lightwas iluminatedon _ acontroLpaneL there but_this relied_solely_on_the_reactions of_one individuaL_who_was_not_necessarly_frst_aid_trained and_if the_receptionist did call 999_ shhe_would not necessarily know the nature of the emergency In this instance the receptionlst who called an ambulance did not know that Mr ALHirsihad suffereda cardiac arest 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 quarterly basis from 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 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 t0 roll it out across its estate_ 6_ Ihe_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_himi_and_failing_that_by_ringing _the_dutv manager's mobile phone:The receptlonist gave evidence that the radios often didnt work though_the_regional manager_disagreed When_the_receptionist was notifed that there_was an emergencyshe 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 _js a poor_reception in_the_plant [oom where he was working 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 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. from Duty
There_seemed a Jack of_meaningful_awareness of_the_defbrillator_Jocatlon_and function_The_first_ person trained in CPR (cardiopulmonary resuscitation) to respond tothe_calls_for_help_was freelance_personaL_trainer_who_was pot member_of Bannatynestafi Although he_was trained_hedid not_take the defbrillator (there was only one_and was Jocated in the_gm)with himbecause at that stage he dd not know_that MrAl-Hirsi_hadsuffered a cardiac arrest_Some_staft members_had not received_defbrillator_training When _ the personaL trainer_reached_MrAL-Hirsi_and [ealised the exact nature of the emergency_the only other person on poolside atthat point _who seemed confdent_of_the location_of_the defbrillator_wasa club member whohappened to be a retired doctoc 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 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: 8 The_pooL was not under_continuous supervlsion and there_was no legal requirement fora lifequard_but it was under CCIV surveillance_However_the camera wasplaced atuin such a position that itcould not detect_what_was _happening under water_and there_was a blind_spot_in_that_part of_the_pooknearest the cameraAfer Mr ALHirsi slipped under water_hewas completely_invisible_to thecamera 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. 9_ TheCCLVmonitor_was In reception_This_was meant_to_be_obseryed_every 15 minutes (tq 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_ thehead of the receptionist__so itwas never in her nomalfeld of view_She_had to turn her_back on the public to lookatit
The Company has moved the CCTV monitor at its Maida Club to 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_
10. The_wtten_procedures_did_not_detaiL_the_action_that should_be_taken on noting a bather_In dificulty:_ talked about RLSS (Royal Life_Saving SocietvL techniques being_used_but_these_were never_taught;_and the_duty manager_at_thetime_gave evidence_that he did not ever remember reading the standard operating procedures oremergency 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 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 stakeholderslsuppliers. 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. Qfparticular_concer _to me_js that_ten months following MrALHirsis 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 stafif_water_safety_awareness_training_Some [efresher_training is being_given but_this_was_onlystarted_twoweeks before_the inquest began on Monday_ and stilLno 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 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: they
2. Nothought_appeared to_have_been_given _to the_fact_that_the_cleaner_who_often partnered Mr AL-Hirsiin _thepool cleaning processstanding on poolsideand directing bim_was _ anon-swimmer_and_not_confident_to enter the_water_even ata depthof L5mlntheevent_she relied on a 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 Fomm 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. 3_ Members of_staf had not been given any water safety awareness training_Some did pothave _ aproper_understandingof_the_wavs_In_which a person in dificultv_in the water_may present_for_example that_ they wlL nt necessarily wave in distress_and that_ they may sink rather_than foat_MrALHirsi simply sank to the_bottom of the pooL Bannatyne's had not trained staff_in the_use of_pooL lifesaving aids_The cleaner who Irst tried to help MrAL Hirsi attempted to poke him_with a float_but the dloat did what iwasmeanto itiloated
In January 2018, the Company employed two new members of staff; Health & Safety Compliance Manager (who was previously employed by the Company's Primary Authority) and Learning & Development Manager to improve its training and compliance. Subsequent to this, the Company procured and, in May 2018, launched 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 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.
4. Some members_of_stalf_did not know the exact location of the_panic buttons_nor the circumstances in which they should bepressed_The_panic buttons did not soundan audible alarm throughout the buildingSQ anyone pressing a button would not know if ithad alerted others_and staff elsewhere (other than at reception) would be unaware that_ there_was an emergency_Itdid not occur to the cleaner who first realised that Mc AL-Hirsi_was In difiiculty_to_press the alarm but even if_ she_had_thls would not have brought other staff nunning tohelp 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 are aware of the location and use of the building's emergency and Iife 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 October 2018. they - Giving they
5_ The_panlc _button alarm was audble bY a beeplng sound In reception anda lightwas iluminatedon _ acontroLpaneL there but_this relied_solely_on_the_reactions of_one individuaL_who_was_not_necessarly_frst_aid_trained and_if the_receptionist did call 999_ shhe_would not necessarily know the nature of the emergency In this instance the receptionlst who called an ambulance did not know that Mr ALHirsihad suffereda cardiac arest 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 quarterly basis from 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 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 t0 roll it out across its estate_ 6_ Ihe_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_himi_and_failing_that_by_ringing _the_dutv manager's mobile phone:The receptlonist gave evidence that the radios often didnt work though_the_regional manager_disagreed When_the_receptionist was notifed that there_was an emergencyshe 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 _js a poor_reception in_the_plant [oom where he was working 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 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. from Duty
There_seemed a Jack of_meaningful_awareness of_the_defbrillator_Jocatlon_and function_The_first_ person trained in CPR (cardiopulmonary resuscitation) to respond tothe_calls_for_help_was freelance_personaL_trainer_who_was pot member_of Bannatynestafi Although he_was trained_hedid not_take the defbrillator (there was only one_and was Jocated in the_gm)with himbecause at that stage he dd not know_that MrAl-Hirsi_hadsuffered a cardiac arrest_Some_staft members_had not received_defbrillator_training When _ the personaL trainer_reached_MrAL-Hirsi_and [ealised the exact nature of the emergency_the only other person on poolside atthat point _who seemed confdent_of_the location_of_the defbrillator_wasa club member whohappened to be a retired doctoc 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 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: 8 The_pooL was not under_continuous supervlsion and there_was no legal requirement fora lifequard_but it was under CCIV surveillance_However_the camera wasplaced atuin such a position that itcould not detect_what_was _happening under water_and there_was a blind_spot_in_that_part of_the_pooknearest the cameraAfer Mr ALHirsi slipped under water_hewas completely_invisible_to thecamera 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. 9_ TheCCLVmonitor_was In reception_This_was meant_to_be_obseryed_every 15 minutes (tq 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_ thehead of the receptionist__so itwas never in her nomalfeld of view_She_had to turn her_back on the public to lookatit
The Company has moved the CCTV monitor at its Maida Club to 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_
10. The_wtten_procedures_did_not_detaiL_the_action_that should_be_taken on noting a bather_In dificulty:_ talked about RLSS (Royal Life_Saving SocietvL techniques being_used_but_these_were never_taught;_and the_duty manager_at_thetime_gave evidence_that he did not ever remember reading the standard operating procedures oremergency 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 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 stakeholderslsuppliers. 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. Qfparticular_concer _to me_js that_ten months following MrALHirsis 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 stafif_water_safety_awareness_training_Some [efresher_training is being_given but_this_was_onlystarted_twoweeks before_the inquest began on Monday_ and stilLno 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 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: they