Source · Prevention of Future Deaths

Josephine Foday

Ref: 2014-0301-wp24614 Date: 23 May 2014 Coroner: Caroline Beasley-Murray Area: Essex 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner noted the swimming pool's inherently dangerous profile, inadequate risk assessments, and insufficient supervision without lifeguards or effective CCTV monitoring. Concerns also included unclear signage and a lack of staff trained in aquatic rescue techniques.

Date 23 May 2014

56-day deadline 18 Jul 2014 est. estimated from the report date

Responses identified 1 of 1

Other related deaths

Coroner's concerns

AI summary

The coroner noted the swimming pool's inherently dangerous profile, inadequate risk assessments, and insufficient supervision without lifeguards or effective CCTV monitoring. Concerns also included unclear signage and a lack of staff trained in aquatic rescue techniques.

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

Letter dated 11 Jul 2014 PDF

AI-classified response stance Action Planned

AI-generated response summary

• IOSH stated it would include a summary of the key findings in the September 2014 issue of its member magazine, the Safety and Health Practitioner. • IOSH stated it would include a news item in its e-bulletin, Connect, on Monday 21 July.

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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Shared signals

Report details

Reference: 2014-0301-wp24614
Date of report: 23 May 2014
Coroner: Caroline Beasley-Murray
Coroner area: Essex

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: 18 Jul 2014 (estimated from the report date).

Sent to

Chartered Institute of Environmental Health and Institute of Occupational Safety and Health

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.