Source · Prevention of Future Deaths

Komba Kpakiwa

Ref: 2014-0301 Date: 23 May 2014 Coroner: Caroline Beasley-Murray Area: Essex Responses identified: 1 / 2 View PDF

The pool had an inherently dangerous profile with inadequate risk assessments, no lifeguards, ineffective supervision (unmonitored CCTV), unclear signage, and untrained staff in aquatic rescue.

Date 23 May 2014

56-day deadline 18 Jul 2014 est.

Responses identified 1 of 2

Other related deaths

Coroner's concerns

AI summary

The pool had an inherently dangerous profile with inadequate risk assessments, no lifeguards, ineffective supervision (unmonitored CCTV), unclear signage, and untrained staff in aquatic rescue.

View full coroner's concerns

1) The pool profile was inherently dangerous
2)The pool profile, including depths and gradients were not considered when carrying out the hazard identification that is required in the swimming pool guidance document HSG 179
3) The risk assessments did not cover the accurate profile information and any other specific risk factors
4) There were no lifeguards provided and the duty holders of the pool did not ensure that there were in place effective controls in place to reduce the risk of drowning
5) It did not appear that non swimmers or poor swimmers had been considered in the risk assessment process.
6) The pool operators had not sought the advice of a swimming pool expert in order to decide what would constitute adequate controls where constant pool supervision was not provided in this unusual hopper type pool. The operators were relying on CCTV as a method of supervision but this was not monitored and no system was put in its place when it became unavailable.
7) Some of the signage provided was not clear, accurate and unambiguous.
8)The pool operators did not ensure that in a pool of over 1.5m depth there were always on the premises, when the pool was open, staff trained in aquatic rescue techniques. .

Responses

1 respondent

IOSH

11 Jul 2014 PDF

Action Planned

IOSH will raise awareness among its 44,000 members regarding the deaths of hotel swimming pool users by including a summary of the key findings in the next issue of their magazine and a news item in their e-bulletin. (AI summary)

View full response

Dear Ms Beasley-Murray Further to your correspondence regarding the deaths of hotel swimming pool users Josephine and Komba Kpakiwa, in which you seek IOSH assistance to help prevent further such tragedies_ We understand that the swimming pool concerned is now closed and so no-one else will be put at similar risk in this facility: In our capacity as a professional body for occupational safety and health practitioners , we will raise awareness among our 44,000 members by highlighting the facts of this case, the concerns raised and the Health and Safety Executive guidance on this topic. To this end, we will be taking the following actions: Including a summary of the key findings in the next available issue (September 2014) of the Institution's official member magazine the Safety and Health Practitioner Including a news item in our e-bulletin, Connect, on Monday 21 July, which is distributed to all our members. We note that you have written to the Chartered Institute of Environmental Health and would also suggest that you contact the Royal Society for Prevention of Accidents (RoSPA); which has a Leisure Safety Department specifically covering water safety, to further raise awareness of this incident_ Ydurg Bincerely Jarl Chmiel Chtef Executive Institution of Occupational Safety and Health Founded 1945 inccrporated by Ryal Charter 2003 Regiztered cnarity' !095790 Recognised b; 'he ILO as an F TCR 0 FBOPLF International ;'GC Foday

Report sections

Investigation and inquest

On 29 April 2013 I commenced an investigation into the deaths of Josephine Foday and of Komba Kpakiwa. The investigation concluded at the end of the inquests on 15 May 2014. The conclusions of the inquests were Accident. Natural The cause of death for both 1a) consistent with drowning.

Circumstances of the death

Both Ms Foday and Mr Komba were found floating in the swimming pool at Down Hall Country House Hotel, Hatfield Heath, Essex. Their deaths were confirmed shortly thereafter.

Copies sent to

copy of your responseHM Senior Coroner for Essex

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Report details

Reference: 2014-0301
Date of report: 23 May 2014
Coroner: Caroline Beasley-Murray
Coroner area: Essex

Responses identified

Responses identified 1 of 2

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 18 Jul 2014 (estimated).

Sent to

Chartered Institute of Environmental Health

Institute of Occupational Safety and Health

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.