Keenan Walsh
PFD Report
All Responded
Ref: 2016-0202
All 2 responses received
· Deadline: 22 Jul 2016
Coroner's Concerns (AI summary)
Unregulated private holiday swimming pools, non-standard pool design, and inadequate adult supervision ratios created significant safety hazards for children.
View full coroner's concerns
_ At the time of the incident private holiday lets with swimming were not regulated by the Health and Safety Department of Local Authority Environmental Health, despite tourism being a sichificant of local economy See recording of evidence of Environmental Health Officer (North Devon Council).
(2) Although there was a limited amount of signage the profile of the swimming pool fell outside accepted standards and presented significant hazard to non-swimmers approaching sharp slope to the deep end.
(3) The ratio of competent adults to children was one adult to anything up to 12 children at the time of this incident_ This ratio was against the advice of the proprietors but unenforceable Responsibility lay with adult family members.
(2) Although there was a limited amount of signage the profile of the swimming pool fell outside accepted standards and presented significant hazard to non-swimmers approaching sharp slope to the deep end.
(3) The ratio of competent adults to children was one adult to anything up to 12 children at the time of this incident_ This ratio was against the advice of the proprietors but unenforceable Responsibility lay with adult family members.
Responses
Noted
Devon County Council acknowledges the coroner's concerns, notes that responsibility lies with District Councils, and will raise the issue with the 'Visit Devon Community Interest Company'. (AI summary)
Devon County Council acknowledges the coroner's concerns, notes that responsibility lies with District Councils, and will raise the issue with the 'Visit Devon Community Interest Company'. (AI summary)
View full response
Dear Dr Earland Re: Regulation 28 Report into the death of Kennan John WALSH DOD 24.08.2013 Inquest 23 25 2016 We write further to your Regulation 28 Report sent on 27 May 2016, your letter of 20 June 2016 and your letter of 4 July 2016. You helpfully explained that the purpose of a Regulation 28 Report is to identify those authorities who have the power to make changes to improve practice which may prevent further deaths and to bring the relevant circumstances to their attention. We note the content of North Devon Council's response and agree with them that the responsibility for enforcing health and safety in holiday lets sits with District Councils across Devon_ In light of this Devon County Council has no power to make changes to improve practice as that power is in the hands of the District Councils Devon County Council no longer undertakes tourism operational activities as these are in the process of being transferred out to the 'Visit Devon Community Interest Company however, Devon County Council shall raise the issue with this organisation so that it may raise awareness of the issue across Devon: Yoursasincere For thle County Solicitor May
Action Planned
North Devon Council is seeking counsel's opinion on the scope of S3(2) Health and Safety at Work etc Act 1974 and will share this with other local enforcing authorities in Devon to inform the development of intervention plans; the tourist industry in the county will be advised accordingly. (AI summary)
North Devon Council is seeking counsel's opinion on the scope of S3(2) Health and Safety at Work etc Act 1974 and will share this with other local enforcing authorities in Devon to inform the development of intervention plans; the tourist industry in the county will be advised accordingly. (AI summary)
View full response
Report to Dr Elizabeth A Earland HM. Senior Coroner North Devon Council's response to your Regulation 28 Report to prevent future deaths_ Keenan John WALSH Deceased Inquest: 23 25 2016, Devon County Hall; Topsham Road, Exeter North Devon Council's (NDC) responsibilities for enforcing health and safety. NDC is an authority responsible for enforcing health and safety by virtue of S18 Health and Safety at Work etc Act 1974_ The Health and Safety (Enforcing Authority) Regulations 1998 allocate responsibility for the enforcement of health and safety in holiday lets to local authorities where temporary or permanent accommodation is provided for more than 20 weeks_ In 2013 HSE published the National Local Authority Enforcement Code (the Code): The Code was developed in response to the recommendation in "Reclaiming health and safety for all: an independent review of health and safety legislation" by Professor Ragnar Lofstedt for HSE to be given a stronger role in directing Local Authority (LA) health and safety inspection and enforcement activity and as an outcome of the Red Tape Challenge on health and safety_ The Code is designed to ensure that LA health and safety regulators take a more consistent and proportionate approach to their regulatory interventions_ It sets out the Government expectations of a risk based approach to targeting: In 2016 the HSE issued Local Authority Circular (LAC 67/2 (rev 5)) to provide guidance and tools for priority planning and targeting these interventions to enable them to meet the requirements of the Enforcement Code_ The LAC identifies 10 activities/sectors where it is appropriate for local authorities to carry out proactive inspections_ These are based on national priorities. This list does not include managing safety in swimming pools. The LAC also allows for the development of local intervention plans which are based on a regionalldistrict needs assessment: For a number of years swimming pool safety has been identified as a local priority in NDC's intervention plan. NDC's performance in enforcing swimming pool safety NDC's performance in relation to the proactive inspection of swimming pools is set out in Appendix 1_ May May May
While there are no swimming pool specific health and safety laws, officers require operators to comply with the general duties under the HSWA 74 and associated regulations Officers refer to and promote the guidance, issued by the HSE entitled 'Managing health and safety in swimming pools' This is available at wwhsegov uklpubnslbookslhsg179htm There is no requirement to registerllicence a swimming pool and this makes it more challenging for regulators such as NDC to maintain an up to date data base_ NDC's enforcement of health and safety at Bicclescombe Grange, Score View, Ilfracombe, EX34 8ET. The operator has complied with the works the investigating officer set out in relation to health and safety contraventions regarding signage and access to the swimming pool. The operator has given a commitment to re profile the pool before the end of September 2016. This control was set out as recommendation; The Council is seeking counsel's opinion so that it can better advise its enforcement officers on the scope of S3(2) Health and Safety at Work etc Act 1974 (duties of self employed persons to persons other than their employees): This opinion will be shared with the other local enforcing authorities in Devon via the Chief Environmental Health Officers Health and Safety Sub Group. This will inform the development of all Local Authority intervention plans across Devon and the tourist industry in the county will be advised accordingly. Summary NDC will continue to invest resources in enforcing swimming pool safety, this is a local priority. NDC will share the outcome of this inquest and counsels opinion with other health and safety local authority regulators in Devon; with a view to enhancing the effectiveness and consistency of all local authority intervention plans in the region. Mike Mansell Chief Executive North Devon Council 28th June 2016 UGpusl
While there are no swimming pool specific health and safety laws, officers require operators to comply with the general duties under the HSWA 74 and associated regulations Officers refer to and promote the guidance, issued by the HSE entitled 'Managing health and safety in swimming pools' This is available at wwhsegov uklpubnslbookslhsg179htm There is no requirement to registerllicence a swimming pool and this makes it more challenging for regulators such as NDC to maintain an up to date data base_ NDC's enforcement of health and safety at Bicclescombe Grange, Score View, Ilfracombe, EX34 8ET. The operator has complied with the works the investigating officer set out in relation to health and safety contraventions regarding signage and access to the swimming pool. The operator has given a commitment to re profile the pool before the end of September 2016. This control was set out as recommendation; The Council is seeking counsel's opinion so that it can better advise its enforcement officers on the scope of S3(2) Health and Safety at Work etc Act 1974 (duties of self employed persons to persons other than their employees): This opinion will be shared with the other local enforcing authorities in Devon via the Chief Environmental Health Officers Health and Safety Sub Group. This will inform the development of all Local Authority intervention plans across Devon and the tourist industry in the county will be advised accordingly. Summary NDC will continue to invest resources in enforcing swimming pool safety, this is a local priority. NDC will share the outcome of this inquest and counsels opinion with other health and safety local authority regulators in Devon; with a view to enhancing the effectiveness and consistency of all local authority intervention plans in the region. Mike Mansell Chief Executive North Devon Council 28th June 2016 UGpusl
Sent To
- Devon County Council
- North Devon Council
Response Status
Linked responses
2 of 2
56-Day Deadline
22 Jul 2016
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 16 September 2013 commenced an investigation into the death of Keenan John WALSH, aged 4 years The investigation concluded at the end of the Inquest on Wednesday 25 May 2016. The conclusion of the Inquest was a Narrative Conclusion details as follows: "Keenan; a non-swimmer; died as a result of a tragic drowning accident in the 9 foot deep end of heated swimming at Bicclescombe Grace, Kingsley Avenue, Ilfracombe, whilst attending a large family party: Sometime between 17:45 hours and 18.17 hours 23 August 2013, Keenan submerged in the deep end of the pool whilst inadequately supervised in company of a permutation of 12 children jumping in and and two adults; neither of whom were available to rescue him. The slope of the deep end was & factor: Vision was obscured by large numbers of inflatables Immediate attempts at resuscitation and subsequent transfer to North Devon District Hospital; then Paediatric Intensive Care Unit at Bristol Children's Hospital, failed to avert his subsequent death from Ia. Complications of near-drowning: pool out
Circumstances of the Death
See 3 above
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you your organisation have the power to take such action refer you to the advice received in Evidence from Environmental Health Officer in her report_ "Pool Profile The gradient of the swimming pool in_water depths of 1.5m and 1.35m had been calculated as approximately 1 in 3.7. This means that the does not comply with either the new European Standard BS EN 15288-2.2008 or the standard outlined in HSG these in and in 15 respectively: The Officers have strongly recommended that the owners consider re-profiling the floor of the to gradient which meets the requirements of those standards. In the meantime Officers recommended that: a) diagram showing depth and profile should be displayed poolside. b) The sides Of the pool should be clearly marked at areas of steep gradient with signs erected warning of the sudden change in depth. c) To consider the possibility of introducing & physical barrier between the changes of waler depth. This could include the provision of floating buoys, for example. d) Consider clearly marking the areas of steep gradient with coloured tank markings: Signage Clear; water depth signs should be provided which are clearly visible to the bathers,_when they are both 0n the pool surrounds and in the water will my pools part pool being pool pool pool b) Signs indicating general 'do's and 'don'ts' should be placed prominently poolside. Warning signs such as 'No Diving', etc , should be displayed in pictorial format to comply with the Health & Safety (Safety & Signals) Regulations 1996. Access to Pool a) A high handle, 'out of reach' of younger children should be provided on the main entrance door to the hall: b) Access to the pool hall is located close to deep water Bathers may enter the water at the first entry point without checking that the water depth is appropriate particular problem for children and inexperienced swimmers: suggested that physical barrier such as guard-rail could be provided. Under the circumstances we would agree that a guard-rail and warning signs would be appropriate. Further to this she stated in Evidence that it had recently been decided by the Legal Department that such holiday lets would fall to be included with the provisions of Section 3 Health and Safety at Work Act 1974 (the proprietors self-employed). If this is SO invite you to clarify this point with all involved in the tourist industry in the county and take such action as is felt necessary_
Inquest Conclusion
"Keenan; a non-swimmer; died as a result of a tragic drowning accident in the 9 foot deep end of heated swimming at Bicclescombe Grace, Kingsley Avenue, Ilfracombe, whilst attending a large family party: Sometime between 17:45 hours and 18.17 hours 23 August 2013, Keenan submerged in the deep end of the pool whilst inadequately supervised in company of a permutation of 12 children jumping in and and two adults; neither of whom were available to rescue him. The slope of the deep end was & factor: Vision was obscured by large numbers of inflatables Immediate attempts at resuscitation and subsequent transfer to North Devon District Hospital; then Paediatric Intensive Care Unit at Bristol Children's Hospital, failed to avert his subsequent death from Ia. Complications of near-drowning: pool out
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.