Gerrard-Junior Raunga Williams-Boglieka got into trouble after repeatedly spinning around, losing his balance and falling in water about a metre-deep in the 25m training pool. File photo. Photo: 123rf.com
The death of a seven year old boy at a Whanganui public pool is a stark reminder of the speed at which children can drown, a coroner says.
Gerrard-Junior Raunga Williams-Boglieka died at the Whanganui District Council run Splash Centre in July 2020.
Robin Kay has recommended that an extra lifeguard be rostered on at all times the complex and that the council invest in technology which uses cameras and artificial intelligence to analyse the behaviour of pool users, and alerts lifeguards to potential drowning incidents via smartwatches and office dashboards.
Chief executive David Langford said after reviewing the recommendations, the council had already added an extra lifeguard at the pool, begun to gather information on using an AI drowning prevention system, and as an extra measure removed partitions to improve visibility for lifeguards.
"This was a tragic event and our heartfelt sympathies are with Gerrard's whānau and loved ones," he said.
Gerrard - who was at the complex with his mother, grandmother and three siblings - got into trouble after repeatedly spinning around, losing his balance and falling in water about a metre-deep in the 25m training pool.
Events leading to his death were caught on CCTV.
"At approximately 1:50pm, Gerrard was standing in the pool when he began to spin around - he spun around approximately 30 times, with his arms, head and neck above the water," the coroner's report said.
He stopped and picked up a football that was floating nearby, held it out of the water and spun about another 20 times. As he spun, Gerrard moved closer to a raised bulkhead at the end of the training pool.
"Gerrard then lost his balance and footing, and fell down into the water. CCTV footage captured splashes in the area where Gerrard was last seen above
the water, at which point his arms were out of the water. Gerrard then floated face down in the pool, in the vicinity of some steps."
After about three minutes, a member of the public drew a lifeguard's attention to Gerrard and about 30 seconds later the boy was lifted out of the pool and the alarm raised.
A lifeguard and a member of the public performed CPR while emergency services were called and resuscitation attempts continued, until he arrived at Whanganui Hospital where he was pronounced dead.
Worksafe investigated and did not find any failings in Splash Centre's operations.
It asked an occupational medicine specialist whether spinning in the water could cause a person to lose consciousness, increasing the risk of drowning.
The specialist said that prolonged spinning could have caused a drop in blood pressure leading to the 7-year-old, who had no previous medical conditions, fainting.
"When a person faints, it usually results in them dropping to the ground and lying in a horizontal position - this helps to restore the person's blood pressure, and them regain consciousness. However, in an aquatic environment the unconscious person would rapidly inhale water and drown," they said.
WorkSafe issued an safety alert to Recreation Aotearoa and Poolsafe, recommending that all swimming facilities be made aware of the critical risk that any spinning-type activity in an aquatic environment created, asking that it cease immediately
Its report also recommended that children under the age of 8-years-old be readily identifiable - for example by the use of wristbands - and caregivers given easily understood information on the meaning of "close supervision".
Coroner Robin Kay sought the opinion of a paediatric neurologist on spinning.
"It was the opinion of the neurologist that Gerrard became disorientated by more than one minute of continuous, vigourous rotations, lost his balance and fell into the water. He was then unable to orient himself to regain his footing, panicked and inhaled water, causing him to drown."
The coroner also investigated why no-one saw the boy was in trouble.
His mother was busy with three of Gerrard's siblings while his grandmother was momentarily distracted putting away her mobile phone after taking photos of the children playing, Kay's report said.
"When she finished doing so, she heard someone shout out and then saw lifeguards pull Gerrard from the pool."
The coroner found that the lifeguards were suitable trained and aware of blindspots in the complex.
CCTV footage showed that shortly before Gerrard got into trouble lifeguards swapped positions briefly before the staff member covering the training pool and toddlers pool returned to their position.
"Critically, CCTV footage shows that as the lifeguard walked along the end of the pool, and when Gerrard was in difficulty, the lifeguard's view into the pool was blocked by a man walking with two children between the lifeguard and the end of the pool.
"In the few seconds it took for the lifeguard to return to their position between the end of the training pool and the toddlers pool, Gerrard had floated towards the corner of the pool where the raised bulkhead of the pool obscured the lifeguard's view, meaning they were unable to see Gerrard."
Nobody else saw or heard the boy get into trouble.
Kay said no single factor caused Gerrard's death but several contributed to it and had any one one of those factors not been in play he would likely have survived.
"The first factor, and it is important to state that I am in no way being critical of Gerrard for this, was the spinning he did in the pool. If he had not spun as he did, he would not have lost balance, found himself unable to raise himself above the surface of the pool, and thereby drowned."
The second was that no-one saw him get into trouble.
The coroner said Gerrard's death was a stark reminder of the speed at which children could drown.
"Even in environments that seem benign - in this case, a shallow, uncrowded pool with which Gerrard and his whānau were familiar, which was staffed by properly trained lifeguards of a number consistent with industry guidelines, and with members of his whānau (including two adults) nearby."
Kay said employing an extra lifeguard at Splash Centre would allow two lifeguards to be assigned to monitor the training pool, where Gerrard died, rather than covering the training pool and the toddlers pool.
"An extra lifeguard at the toddler pool end of the training pool would overcome the blind spot created by the bulkhead that obscured the lifeguard's view when Gerrard got into difficulty."
Drowning prevention technology similar to that employed at the Selwyn Aquatic Centre would alert lifeguards to a person who may be getting into, or was already in, difficulty in a pool, Kay said.
"That early detection would enable a lifeguard to respond, assess the situation and intervene if required. By doing so, the likelihood of further drownings occurring would be reduced."
Kay noted Recreation Aotearoa had amended its Aquatic Facility Guidelines to reflect the Worksafe safety alert about the dangers of activities which might cause a person to faint or lose their balance near water, readily identifying children under the age of eight and providing information on active supervision.
He offered his sincere condolences to Gerrard's whānau and his friends for their loss.
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