When poor documentation, supervision, communication, understanding and implementation nearly led to a fatality
What happened?
A 3 year-old girl was in a swimming pool free-play session at Bishopsgate School in Egham, Surrey while attending a holiday camp for children run by Oxford Active Ltd in July 2023.
The girl was part of a group of nineteen children aged between three and five who were taking part in the session. Most of the children were non-swimmers, including the three-year-old girl. Staff had fitted her with two sets of armbands and provided her with a foam noodle before she entered the pool.
A number of floats were present in the pool, including a large rocket-shaped float. The girl was found face down in the swimming pool underneath this float and was not breathing. The child had become trapped. When she was found unconscious, she was no longer wearing the armbands or using the noodle. Staff intervened and were able to resuscitate her.
An investigation by the HSE found that the leisure company’s documentation relating to pool safety and supervision was insufficiently detailed and lacked clarity. The investigation also found that the content of this documentation was not communicated effectively to staff, meaning appropriate control measures were not properly understood or implemented.
Legal Outcome
Oxford Active Ltd pleaded guilty to breaching Section 3(1) of the Health and Safety at Work etc. Act 1974 in January 2026. The company was fined £6,000 and ordered to pay £12,000 in costs at a hearing at Chichester Crown Court.
What can we learn from what happened?
Happily the girl was fine. It was a near miss and the company were prosecuted for their unsafe working practices.
With many cases like this that involve water-based incidents that have occurred due to a combination of swimmer movement and behaviour, and staff supervision, it is difficult to know exactly what happened and why, without second-by-second information.
The HSE report, as usual, only provides very general information about documentation being insufficiently detailed and poor communication. Nevertheless, this near miss case illustrates the importance of these controls, and the need for second-by-second analysis demonstrates that these supervision-based controls need to be implemented on a second-by-second basis.
Source of Information
HSE Press Release