Case Summary: Adrian Miles

CASE SUMMARY

Adrian was Managing Director of Folex Limited, a company that produced and factored polyester-based film products. As a former army officer, he had served in the Royal Anglia Regiment (Irwin Mitchell, 2007; Express & Star, 2008). He was 48 years old and a father of three children when on Thursday, 27 July 2006, he attended the swimming pool at Gorway road, Walsall campus of Wolverhampton University and drowned (Wilkes, 2009).

Adrian entered the pool at around 17:00. He was utilising a roped-off single lane and a snorkel attachment which the centre had agreed Adrian could use to assist his rehabilitation following an accident in 2005 that had left him recovering from paralysis. This was not the first time Adrian had visited the centre under such arrangements. Adrian entered the water and began swimming as normal. The pool was 25 metres by 10 metres and had two lifeguards on duty; Alex Cotterill and Mr Richard Leek. The pool was quiet, with less than 15 people in the pool at the time of the accident. At around 17:50, Adrian was spotted on the bottom of the pool by another pool user. Mr Cotterill and Mr Leek recovered Adrian from the water and began resuscitation. He was transferred by paramedics to Walsall Manor Hospital before being pronounced dead later the same day. There were no witnesses who saw Adrian in difficulty or anyone who could confirm how long Adrian had been on the bottom of the pool.

In 2005, Adrian played a charity rugby match for Walsall Rugby club, where he suffered severe bruising to his spine when he was injured whilst going into a tackle at Wednesbury in May last year (Birmingham Live, 2006). The accident resulted in Adrian being airlifted to Selly Oak Hospital and then transferred to the Royal Orthopaedic Hospital in Oswestry. The accident left Adrian recovering from temporary paralysis for ten days following the accident.

Adrian took up swimming at the Gorway Road swimming pool after his accident as a therapeutic exercise and to aid his recovery. He had been using the pool regularly for two months prior to the accident. He went from having no feeling or movement in his limbs to being able to walk with a single crutch, swim 30 lengths and drive a car. Medical staff were astounded at the extent of his recovery. Mr Miles was using a mask and snorkel and was swimming in his own roped-off lane to enable him to swim front crawl without the need to rotate to breathe (something his injury limited him from doing). Mr Miles was undergoing hydrotherapy at the pool at other times in the week and was known to staff at the facility (Wilkes, 2009). Prior to the accident, he had regained about 80% of his mobility.

The University of Wolverhampton’s senior pro-vice-chancellor Garry Sproston said on behalf of the University (BBC, 2006):

Two lifeguards pulled the member of the public from the water and performed CPR until ambulance crews arrived. The man was taken to Walsall Manor Hospital, where he was pronounced dead. Our deepest condolences go to his family.

Police arrived and the pool was closed for the rest of the day. The Health and Safety Executive have been informed of the incident and we are conducting an internal inquiry to determine the full facts. We take safety very seriously at the University and have trained lifeguards on duty at all times at the pool. We will continue to co-operate the pool whilst we investigate.

Mr David Rogers, secretary of Walsall Rugby Club, said in tribute to Adrian (Birmingham Live, 2012):

Adrian was very well respected and liked within the club, both as a past player and as a coach with the under-13s. Adrian was a very keen player and suffered severe spinal injuries when he was injured going into a tackle during a fun day at Wednesbury Rugby Club in May last year.

He was left paralysed from the neck down for several weeks and was in the Robert Jones and Agnes Hunt Orthopaedic Hospital at Oswestry for more than two months. But he was well on the road to recovery and although he was never going to be able to play again, he had fought his way back to 75 or 80 per cent full fitness.

He was swimming as part of his training regime when the tragedy happened, and his death has left a tremendous void at the club. He was an active playing member of the club until his playing accident on May 1 last year. But he was back home, back at work and able to drive again.

It's such a tragedy. He was fighting back after an awful playing accident and then drowned as part of his rehabilitation and recovery regime which he had worked out for himself.

 

Coroner’s inquest (2006) (Friday 1 September, Dudley Coroner’s Court)

The coroner’s inquest began on Friday 1 September 2006 at Dudley Coroner’s Court by Coroner Robin Balmain. It did not conclude until Tuesday 29 May 2007. Mr Balmain, a solicitor, became a coroner in 1972 before later retiring in 2014 (after 40 years of service), carrying out on average 500 inquests per year. Mr Cotterill and Mr Leek both declined to give evidence at the inquest. Dr Fiona Reynolds, a consultant at Birmingham Children’s Hospital, said she could not rule out that Mr Miles may have been underwater for some time before his heart stopped.

In my opinion, the fact that Mr Miles was not able to be resuscitated means that he may have been submerged for at least four minutes, but probably longer.

Coroner Balmain was also told by those using the pool at the time of the accident that they thought the lifeguards were not concentrating on the water. The inquest also heard from Mr Adam Ali, who said:

I saw the lifeguards chatting to two women when I entered the pool. 

Ms Sarah Wiseman, who worked at the campus, admitted she was one of the women talking to Mr Cotterill and Mr Leek at the time of the incident and said:

I admit my friend, Ms Lindsey Taylor-Thornley (a swimming teacher), and I spoke to Alex and Richard. We only chatted briefly. My conversation with Mr Leek only lasted a couple of sentences. I was looking to go for a swim, so I popped my head through the door.

At the conclusion of a five-day inquest into his death, the eleven-member jury returned its verdict of accidental death on 29 May 2007. In their narrative verdict, they responded to the questions set by the Coroner and said:

The supervision of the pool was not adequate and not enforced by management. Duty managers did not communicate clearly the safety instructions and operating procedures at the site. Lifeguards did not carry out their duties in accordance with their training.

There is no evidence of detailed assessment by the university to determine if it was safe for Mr Miles to use the pool with his spinal cord injury or that he could use a snorkel and mask. The Normal Operational Procedure itself said that pool users were not allowed to use a snorkel and mask.

We conclude that Mr Miles died from drowning but accept his previous spinal injury was a contributing factor (Wilkes, 2009). 

Adrian’s wife, Mrs Ann Miles, said (Irwin Mitchell, 2007; Express & Star, 2008):

Adrian had made such a fightback from the Rugby injury. There was a time when we thought he would never walk again. The way in which my husband lived his life following the rugby accident was an inspiration not only to me and his family but to everyone who knew him. He battled through it and got back to 80% of his mobility. He fought so hard, despite many setbacks, to do everything he could to aid his recovery.

We are all totally devastated by his loss and the way in which he has been badly let down by the University of Wolverhampton and its staff who we consider owed him a duty of care. Knowing what happened will never bring my husband back, but it is important that those involved understand what went wrong and why Adrian died. We are pleased with the Jury's verdict and hope that this will help to prevent such a tragedy occurring in the future.

Sarah Mullen, a solicitor at Irwin Mitchell, who represented Mrs Miles, said (Irwin Mitchell, 2007):

What happened to Mr Miles was an absolute tragedy. The inquest was an emotional experience for Mrs Miles and her whole family as this has been their first opportunity to hear about and understand the reasons why Adrian came to drown in a supervised public swimming pool.

We believe the evidence heard at the inquest supports our view that the lifeguards should have seen that Mr Miles was in difficulty and had they done so we believe that he would then have been rescued and his life saved.

The inquest has revealed major flaws in the organisation, management and supervision of the swimming pool and the pool staff. I would invite all those responsible for public swimming pools to review their systems to ensure that this tragedy is not repeated.

The Health and Safety Executive made the decision to charge Mr Cotterill and Mr Leek each with a breach of s.7(1) HSWA 1974 on 16 July 2008 (Express & Star, 2008). They appeared before Walsall Magistrates Court on 2 September 2008. They entered a plea of not guilty and were elected for trial in the Crown Court. The Magistrates' allocated the case to the Crown Court.

 

R v Alex Cotterill and Richard Leek (2009) (Wolverhampton Crown Court, 5 October)

On 5 October 2009, the three-week trial began at Wolverhampton Crown Court, presided over by HHJ Michael Dudley. The two defendant lifeguards, Mr Cotterill and Mr Leek, were charged with a single count of breaching s.7(1) HSWA 1974. Both defendants had already entered a plea of not guilty at the Magistrates Court. At the time of the accident, Mr Cotterill was 28 years old, and Mr Leek was 30 years old.

One notable fact about HHJ. After graduating with his LLB at Birmingham University in 1968, he lectured in law at Wednesday College of Commerce and Technology for four years. That college would later become part of Wolverhampton University, the operator of the swimming pool where Adrian drowned in 2006 and the employer of the two defendant lifeguards. James Puzey of St Phillips Chambers, prosecuting on behalf of the HSE, told the Court (Wilkes, 2009):

There were two lifeguards on duty, Mr Cotterill and Mr Leek. Mr Cotterill was responsible for observing the deep end of the pool. Mr Leak was on duty at the shallow end, a couple of feet from the edge of the pool.

Mr Cotterill did not stay in position at the deep end and did not patrol the deep end half of the pool. From the time Mr Cotterill came on duty at 17:05, he spent his time exclusively or almost exclusively near Mr Leek at the shallow end. Both lifeguards were seen standing together chatting to two women near the shallow end (Wilkes, 2009). 

Mr Miles spoke to both lifeguards before his swim when he entered the pool just after 17:00. Mr Miles body was spotted by a swimmer at around 17:50 who alerted lifeguards Cotterill and Leek. They then rescued Mr Miles and recovered him to the poolside.

Mr Miles should not have been at the bottom of the pool for 30 to 40 minutes. It was a small pool, and they knew Mr Miles was in the pool, it wasn’t a busy day. If Mr Leek and Mr Cotterill had been paying attention, how could they fail to notice Mr Miles was no longer swimming.

They were trained and qualified as lifeguards and if they were not paying attention. That was one of the basic failings. Mr Miles should not have been at the bottom of the pool for 30 to 40 minutes. It was a small pool, they knew he was there to swim, it wasn't a particularly busy day.

The court heard that Mr Cotterill was distracted from his duties and was not able to see that Mr Miles had got into difficulties (BBC, 2009). HSE inspector Kanwal Kanda said:

While the lifeguards did not cause Mr Miles to get into difficulty, their neglect of duty was clearly a major factor in leaving him and potentially others using the pool unnecessarily exposed to risk.

Standards are well established through training and they must be applied by lifeguards to ensure swimmers are safe.

The trial also heard that Adrian needed to use a mask and snorkel and a separate lane as he was recovering from temporary paralysis after being injured in a charity rugby match the previous year. Witnesses told how he was talking to female friends about a forthcoming graduation ball rather than patrolling the pool (Hughes, 2009).

The jury retired for 10½ hours before returning with their verdict (Hughes, 2009). On 26 October 2009, the jury found Mr Cotterill guilty of a breach of s.7(1) HSWA 1974. The jury was unable to reach a decision of sufficient majority in the case of Mr Leek. Judge Michael Dudley said (Hughes, 2009):

Mr Cotterill you have been found guilty of failing to take reasonable care of the pool users in his care.

You were not charged with bringing about the death of Mr Miles but for failing to pay adequate attention to the pool you were responsible for supervising.

I take account of the sentencing guidelines and mitigation advanced on your behalf, including your income and the impact on your ability to work. I understand you ceased being a lifeguard shortly after the accident and have since taken work as a supply teacher. I fine you £200 but the real punishment is the conviction which will impact on your future.

 

The procedure when a jury cannot reach a verdict of a sufficient majority

To view a summary of what happens when a jury cannot reach a verdict, see our article here. 

 

References (16)

_{Note: I wish those affected all the best in their future. No part of this article purports to attribute blame. See our methodology page for further details of how these case summaries are constructed.} 

_{BBC News (2006). Inquiry into swimmer’s pool death. (5^th September, 14:01). Available at: http://news.bbc.co.uk/1/hi/england/west_midlands/5316328.stm accessed 18th October 2020.}

_{BBC News (2007). Death pool supervision criticised. (25^th May, 19:05). Available at: http://news.bbc.co.uk/1/hi/england/west_midlands/6693599.stm accessed 18th October 2020.}

_{BBC News (2007). Inquest into player’s pool death. (21^st May, 20:10). Available at: http://news.bbc.co.uk/1/hi/england/west_midlands/6677069.stm accessed 18th October 2020.}

_{BBC News (2009). Lifeguard fined over pool death. (27^th October, 16:21). Available at: http://news.bbc.co.uk/1/hi/england/west_midlands/8328478.stm accessed 18th October 2020.}

_{Birmingham Live (2012). Lifeguards accused of not concentrating chatted briefly. (23^rd October, 17:48). Available at: https://www.birminghammail.co.uk/news/local-news/lifeguards-accused-of-not-concentrating-chatted-41237 accessed 18th October 2020.}

_{Birmingham Live (2012). Void left by tragedy. (23^rd October, 16:19). Available at: https://www.birminghammail.co.uk/news/local-news/void-left-by-tragedy-25957 accessed 18th October 2020.}

_{Birmingham Live (2012). Wolverhampton lifeguard convicted after dad dies in swimming pool. (23^rd October, 19:57). Available at: https://www.birminghammail.co.uk/news/local-news/wolverhampton-lifeguard-convicted-after-dad-106650 accessed 18th October 2020.}

_{Bradley, S. (2009). Lifeguard cleared over swimming pool drowning of Walsall father. (Birmingham Live, 23^rd October, 2012). Available at: https://www.birminghammail.co.uk/news/local-news/lifeguard-cleared-over-swimming-pool-108458 accessed 18th October 2020.}

_{Express & Star (2008). Lifeguards charged after father drowns. (16^th July, 00:00). Available at: https://www.expressandstar.com/news/2008/07/16/lifeguards-charged-after-father-drowns/ accessed on 18^th October 2020.}

_{Express & Star (2007). Criticism for drowning lifeguards. (26^th May, 00:00). Available at: https://www.expressandstar.com/news/2007/05/26/criticism-for-drowning-lifeguards/ accessed 18^th October 2020.}

_{Hughes, C. (2009). £200 fine for pool tragedy. (Express & Star, 27^th October, 00:00). Available at: https://www.expressandstar.com/news/2009/10/27/200-fine-for-pool-tragedy/ accessed 18^th October 2020.}

_{IOL (2009). Drowned dad laid at the bottom of pool. (7^th October, 00:00). Available at: https://www.iol.co.za/travel/world/drowned-dad-laid-at-the-bottom-of-pool-460675 accessed 18th October 2020.}

_{Irwin Mitchell (2007). Swimming pool death. (29^th May, 00:00). Available at: https://www.irwinmitchell.com/news-and-insights/newsandmedia/2007/may/jury-returns-verdict-into-tragic-drowning-of-walsall-man accessed 18^th October 2020.}

_{The Telegraph (2009). Swimmer drowned as lifeguards chatted to friends, court told. (7^th October, 07:00). Available at: https://www.telegraph.co.uk/news/uknews/crime/6266839/Swimmer-drowned-as-lifeguards-chatted-to-friends-court-told.html accessed 18th October 2020.}

_{Wilkes, D. (2009). Drowning father lay at bottom of swimming pool for 40 minutes while lifeguards chatted to girls. (Mail Online, 7 October, 07:24). Available at: https://www.dailymail.co.uk/news/article-1218542/Drowning-man-ignored-40-minutes-lifeguard-chatted-friends.html#ixzz0lLizex4p accessed 18^th October 2020.}

 

Citation: Jacklin, D. 2020. Case Summary: Adrian Miles. Water Incident Research Hub, 7 November.