Coronial Findings Into Public Pool Drowning Released

On July 7th 2017 Coroner Gregory McNamara handed down his findings and recommendations into the 2014 fatal drowning of Mr Tony Guan at a Victorian metropolitan public pool.

Mr Guan was “seen floating face-down” in the warm water pool and was pulled unconscious from the water. Despite the efforts of the facility lifeguards, he was unable to be resuscitated.

It is believed that Mr Guan may have lost his footing in the warm water pool, and due to his muscle weakness (resulting from ALS) was unable to right himself. Tragically, Mr Guan had made the decision to ignore his Doctors recommendations which included, i) wearing a floatation device and ii) being supervised by a carer.

A number of key matters were discussed throughout the six day hearing including;

• Staff training
• Lifeguarding systems
• Non-supervisory tasks
• Equipment availability and
• Supervision of disabled patrons

Similar to other recent incidents there was some contrary evidence and a level of confusion surrounding the supervision at the time whereby:
i) “uncertainty arose from the system which allowed on duty lifeguards to do tasks which took them away from their life saving duties.”
ii) “there wasn’t a clear system in place to ensure transfer of responsibilities.”

The Coroner found the cause of death to be ‘accidental drowning’ and made recommendations.

Recommendation One:
Review of training and procedures to ensure that the duties of life savers are clear when conducting supervisory and non-supervisory tasks.

Recommendation Two:
Review of Pool Operations Manual to clarify the role and duties of lifeguards.

Recommendations Three:
Review training and procedures and continue to engage with Life Saving Victoria recommendations to ensure that staff are trained sufficiently in the need to identify and adequately supervise pool patrons in need of closer supervision, and that staff are doing so.

Recommendation Four:
Review procedures to ensure that safety equipment for lifeguards, and in particular bum bags, is ready and available before a shift begins.

A link to the full report is available below.
http://www.coronerscourt.vic.gov.au/resources/acba412b-ce2c-411d-95a8-643b2c31591d/zechengguan_365814.pdf

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