Case Summary: Elsa Carneau
Apr 10, 2020CASE SUMMARY
Elsa Carneau was a 25-year-old Imperial College graduate and a successful financial analyst in London (Greenwood, 2011). Elsa was a member of the Virgin Active Health Club located at 17a Old Court Plan close to Hyde Park, Kensington in West London (Greenwood, 2011). Virgin Active Kensington remains built to impress with marble, stylish interiors and more than a hint of luxury. Monthly membership costs stretched above £145 (Horrox, 2013b). Elsa attended the Virgin Active by working it around her extraordinarily busy work life as an analyst in the financial sector. Long working hours as an analyst remain commonplace in London but were particularly notable in the aftermath of the financial crisis in 2008, which remained raw in the financial sector firmament for sector workers of the time.
On Saturday 3 December 2011, Elsa arrived at the Virgin Active at Kensington at around 18:00. The contemporary guidance on when lifeguards on health club pools were recommended was Figure 3 in Managing Health and Safety in Swimming Pools (3rd edition). The two key metrics for a health club pool deciding not to provide continuous poolside supervision were ensuring pool water was no deeper than 1.5m and a pool surface area of less than 170m² (typically 20 metres x 8 metres). Other factors relevant to assessment could ordinarily be addressed by adequate rules and remote supervision, provided these are implemented in accordance with the guidance. Virgin Active did not provide continuous lifeguard supervision, preferring a system of periodic poolside checks and CCTV remote monitoring provided at the time by a single camera facing the pool. Pool dimensions were 16 metres by 7.5 metres with a 1.2-metre consistent depth throughout.
Elsa was seen swimming lengths by a fellow pool user, Mr Hill, a subsequent witness to the investigation. He later described witnessing Ms Carneau holding her breath, curled in a foetal-like position, below the surface of the water. Mr Hill, who said that Ms Carneau had spoken to him at the end of the lane shortly prior, went over to check on Ms Carneau. Realising Ms Carneau was in distress and summoning help and assistance, and he recovered Ms Carneau from the water. Elsa was not breathing. CPR was conducted initially by Centre staff and subsequently by emergency services. An automated defibrillator applied multiple shocks in an attempt to restart Elsa’s heart. Elsa was transported to Chelsea and Westminster Hospital but was later pronounced dead the same day by medical staff.
The Ambulance service notified the Police of Elsa’s death in accordance with the protocol for the death of members of the public in a workplace. The Metropolitan Police arrived but concluded that the death was not suspicious. They passed the case to the Coroner.
The initial post-mortem conducted did not establish a cause of death (Gates, 2013). The Coroner opened an inquest into Elsa’s death. Environmental Health Officers at the Royal Borough of Kensington and Chelsea awaiting the conclusion of the Inquest before making a decision to investigate further, as is standard practice.
The coronial inquest into the death of Elsa Carneau (2014) (Unreported, 28 April, Westminster Coroner's Court)
The Inquest took place on 28 April 2014 at Westminster Coroner’s Court, which sat at the High Court in London. Coroner Kevin McLoughlin (now Senior Coroner) chaired the Inquest. Mr McLoughlin was a former Partner at DLA Piper and Eversheds before moving to the bar where he practised at Temple Garden Chambers, specialising in health and safety and personal injury law before moving to his Senior Coroner post and also qualified as a Chartered Fellow of IOSH. It was a jury inquest which means that the jury had the factual role of determining the cause of death. The aim of an Inquest is not to attribute blame, and parties are not cross-examined on their evidence, albeit they sware to the accuracy of the evidence they give orally or in writing.
The jury at the Inquest saw CCTV footage of Ms Carneau getting into the pool at around 18:00 on Saturday, 3 December 2011. The jury observed Elsa swimming twenty-three lengths before getting out of the pool for around thirty seconds before returning to swim two more lengths. Mr Rupert Hill was swimming in the pool at the time Ms Carneau was present on that day. In his evidence at the Inquest, Mr Hill reported noticing Ms Carneau “lying underwater in the foetal position appearing to hold her breath.” He reported that after a minute or two, he proceeded over to Ms Carneau and tapped her leg. There was no response. Recognising the seriousness of Elsa’s condition, he summoned help from Centre staff and other customers who attended poolside in response.
The inquest jury heard how an emergency call was made, and whilst paramedics later arrived, help was also sought from the local fire station who arrived prior to the arrival of paramedics. Ms Roman, who was on shift as Centre staff on the day, said she rushed to the poolside on hearing the alarm (as reported by Cockroft, 2014):
I removed vomit from her face and rolled her onto her side to vomit, then checked her airway. I noticed her stomach muscles in spasm.
The jury also heard how Ms Amy Johnson, a fitness instructor and first-aider at the Centre, also assisted with the resuscitation. The jury also heard how staff were unable to identify and obtain Elsa’s contact details on their computer systems. The jury heard that Elsa had not been asked to complete a customer questionnaire, standard practice for most health clubs at the time. Staff were sent to break into lockers to try to obtain contact details for Elsa’s family, who, as yet, was unaware of her critical condition.
The jury heard that CPR was commenced, and 15 shocks from an automated external defibrillator were provided over the next 50 minutes as fire crews and paramedics tried to save Elsa. The resuscitation was not without issue. Firefighter Ben Young told the Inquest that he saw individual filming the resuscitation who at the time claimed to be a member of staff but was later discovered to be a member of the public. Mr Young asked the man to stop filming, and the person responded that it would be ‘something to remember this by if she survived.’ Fire station manager Brian O’Keefe, who was conducting CPR with Mr Young, instructed Mr Young to take the phone from the man if he would not put it down. Mr Young deleted the video. Paramedic Ms Wendy King, who was supporting the resuscitation whilst setting up vital medical equipment, also witnessed the man videoing the incident and described the act as ‘despicable’.
Mr O’Keeffe expressed concerns about the methods being used to try and revive Ms Carneau by centre staff and the way they handled the situation. His observation was that the club’s first aider Ms Natalia Roman was not using the automated external defibrillator competently. Mr O’Keeffe said that when he and Mr Young arrived, they had to take over the resuscitation until paramedics arrived and had set up their equipment. Mr O’Keeffe reported that Centre staff were “overwhelmed” by the situation (Cockroft, 2014).
After an hour of trying to stabilise Ms Carneau’s condition, paramedics proceeded to transfer her to the accident and emergency department, where they could better continue efforts to resuscitate her. Ms Carneau was transferred to Chelsea and Westminster Hospital but was pronounced dead on arrival.
The Inquest heard evidence from Professor Atholl Johnston, Professor of Clinical Pharmacology at Barts Hospital, The London School of Medicine and Dentistry, and the Queen Mary University of London. Professor Atholl, best-known following the Inquest, for being instructed by UK Prime Minister David Cameron between 2012-2015 to advise on improving conviction rates for driving under the influence of drugs. These were implemented in 2015 with The Drug Driving (Specified Limits) (England and Wales) Regulations 2014, which are key to the amended section 5A of the Road Traffic Act 1988.
Professor Atholl assessed that Elsa had 181 micrograms of alcohol per 100 millilitres of blood sampled. The legal drink-drive limit is 80 micrograms per 100 millilitres of blood (Cockroft, 2014). The Inquest was told that two empty pocket-sized bottles of vodka were also discovered in Ms Carneau’s locker at the Centre (Stevens, 2014).
After an inconclusive first pathology report on the cause of death, Coroner Kevin McLoughlin instructed Senior Forensic Pathologist, Dr Simon Poole, to conduct a second post-mortem. Dr Poole confirmed Professor Atholl’s assessment that Ms Carneau had alcohol in her system at the time of death. Dr Poole also told the Inquest that Ms Carneau’s liver was inflamed, showing chronic alcohol dependency and that there were traces of diazepam in her system. Diazepam is a drug used in the treatment of anxiety, alcohol withdrawal and seizures. Dr Poole gave the cause of death as drowning. The autopsy showed no biological marker that indicated the reason Ms Carneau drowned.
The Inquest also heard how the planned periodic checks had not been carried out on the swimming pool for a considerable time prior to the incident. More details on this are revealed at the subsequent trial. Coroner Kevin McLoughlin quoted Eisenhower in his narrative verdict in relation to the lack of checks stating that ‘the uninspected inevitably deteriorates.’
Post-inquest investigation by the Royal Borough of Kensington and Chelsea
Following the Inquest, Environmental Health Officers from the Royal Borough of Kensington and Chelsea accelerated their investigation. The decision was made to charge Virgin Active with one count of a breach of s.3(1) of the Health and Safety at Work Act 1974 (HSWA) and one count of a breach of Regulation 3 of the Management of Health and Safety at Work Regulations 1999.
R v Virgin Active Health Clubs Limited [2014] (Hammersmith Magistrates Court, 15 October, Unreported)
On 15 October 2014, at Hammersmith Magistrates Court, Virgin Active pleaded guilty to one count of a breach of Regulation 3 of the MHSWR 1999 and one count of a breach of s.3(1) HSAWA (Evening Standard, 2014).
The Crown was represented by Prosecutor James Ageros (QC as of 2015) of Crown Office Chambers and author of one of the main legal texts on health and safety in England and Wales (Matthews, R. and Ageros, J. (2016) Health and Safety Enforcement: Law and Practice (4th edition, OUP: Oxford). Mr Ageros told the Court that the “risks leading to Ms Carneau’s death were entirely foreseeable and that managers were responsible for a string of shortcomings.”
Mr Ageros laid out details of those shortcomings (as reported by Greenwood, 2013):
There had been a catalogue of errors and abnormalities in the risk assessments dated back to 2009. There were serious shortcomings in the management of risk connected with swimming activity at the club. The risks were entirely foreseeable, and staff failed to check the pool every 30 minutes.
Management did not know Elsa’s identity and had to search her clothing after her death. Staff had not been properly briefed on the pool risk. The pool was not manned by a lifeguard or adequately monitored by CCTV. There were no signs to inform visitors the pool was unsupervised. A single CCTV camera was placed at one end of the pool and did not provide a clear view of the part where Ms. Carneau got into difficulty. There were no recorded checks at all on the day. We say there was deliberate falsification of the records to make it seem as though checks, which had not been done, were done. Documents on CCTV checks were falsified in in a ‘distasteful’ bid to cover their tracks.
Virgin Active plead guilty at first instance in the Magistrate’s Court to the two offences as charged. That means, in layman’s terms, there was no trial, and no one heard the evidence in open court facing Virgin Active. This normally allows proceedings to move to sentence, but in this case, there was a dispute between the parties over whether there was a requirement to have constant lifeguard supervision in place. For the Court to sentence Virgin Active correctly, the Defence team applied for a Newton Hearing to be heard prior to sentencing. A Newton Hearing is used to decide key facts on which the parties disagree and which have relevance to the appropriate sentence to be passed.
The Newton Hearing was heard sometime prior to the sentence being passed on 19 December 2014. One of the major challenges of Newton hearings is the lack of closure they can offer to families trying to understand exactly what happened to their loved ones. A quote from Mr Carneau below makes precisely that point following the sentencing hearing, which I give in full below (Evening Standard, 2014).
HHJ McCreath, Honourable Recorder for Westminster, presided over the sentencing hearing at Southwark Crown Court on 19th December 2014. Defence barrister for Virgin Active Dominic Kay (now QC), also of Crown Office Chambers, said Ms Carneau had been admitted twice to the hospital that week for collapsing due to alcohol abuse and that she did not alert staff that she had been drinking prior to entering the pool (Cockroft, 2014).
Mr Simon Antrobus (now QC), also of Crown Office Chambers and represented Virgin Active at the Newton and sentencing hearing, said:
The business deeply regrets the tragedy and an apology counts for very little in the circumstances. The findings of the investigation, damaging and embarrassing as they are, are out of corporate character for the business. No one thought this was a swimming pool that required constant supervision and it demonstrably did not. Staff have been sacked and pools across all 112 Virgin Active clubs now have constant lifeguard supervision.
HHJ McCreath, Honourable Recorder for Westminster, presiding over the Newton Hearing and subsequent sentencing at Southwark Crown Court, said:
The first thing that must be said is a word of sympathy for those who grieve for a young life needlessly lost. A fine cannot be any measure of the value of life that has been lost. It is impossible to demonstrate that the corporate faults of Virgin Active caused this dreadful death so I must punish them not for causing that harm. I must punish them for the culpability they have, the blame they must bear, for failures to make proper assessments of risk and to manage that effectively. This is a company that generally has a good safety record, but it is equally clear in relation to the premises where this event happened, the picture is entirely different.
HHJ McCreath sentenced the club to a fine of £100,000 plus almost £31,741 costs (Spear, 2014). A spokesperson for Virgin Active said following the sentencing:
Elsa Carneau’s family and friends have our deepest sympathy for this tragic accident. Health and safety is of paramount importance in our clubs and with our staff. Following an extensive investigation by the Royal Borough of Kensington and Chelsea and Virgin Active, there had not been any suggestion that Elsa’s tragic death was related to the health and safety standards at our Kensington club. Under HSE guidance, it is not a requirement to have a dedicated lifeguard on duty at the Kensington pool. However, the safety of our members is of primary importance which is why we took the decision in 2012 to exceed the requirements in the HSE guidance and have a dedicated lifeguard on duty at all times at every one of our pools.
Her family believed that she was floating in the water for about four minutes before the alarm was raised by a fellow user. Mr Carneau said following the hearing that (as reported by the Evening Standard, 2014):
It was easy for someone to die there unnoticed. It was an accident waiting to happen. If things had been done properly, I think there’s a chance our daughter may still be alive. They have never apologised, not even a letter – nothing. We are shocked by this. Even the judge had kind words for us, but the organisation has not even apologised. It is arrogant. The fine means nothing. For them, it is petty cash. What’s £100,000 to Virgin? And we still have questions needing answers.
Cabinet Minister and Councillor Tim Ahern for Environmental Health at the Royal Borough of Kensington and Chelsea said (as reported by Horrox, 2013b):
This was a very sad case for officers to investigate. What they found was a failure to have proper procedures and risk assessments in place to ensure safe monitoring of the pool.
References (14)
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.
Brown, D. (2014). Former model died in gym swimming pool after ‘bizarre’ chat with City analyst. (The Times, 28 April, 16:56). Available at: https://www.thetimes.co.uk/article/former-model-died-in-gym-swimming-pool-after-bizarre-chat-with-city-analyst-9nczm5wgpw0 accessed on 24 March 2020.
Cockroft, S. (2014). ‘Fragile’ model who drowned at leisure centre had history of drink problems and fainting and had been in hospital twice before her death due to excess alcohol, Inquest hears. (Mail Online, 30 April, 07:50). Available at: https://www.dailymail.co.uk/news/article-2615817/If-makes-remember-What-gym-worker-said-stood-FILMING-lingerie-model-lay-dying-exercise-centre.html accessed 25 March 2020.
Evening Standard (2011). City woman found floating in pool ‘had heart attack’ (9 Dec, 12:27). Available at: https://www.standard.co.uk/news/city-woman-found-floating-in-pool-had-heart-attack-6377048.html accessed 24 March 2020.
Evening Standard. (2014). Virgin have never said sorry, says father of former model who drowned at health club. (2 January, 12:58). Available at: https://www.standard.co.uk/news/london/virgin-have-never-said-sorry-says-father-of-former-model-who-drowned-at-health-club-9034436.html accessed 24 March 2020.
Gates, J. (2013). Acton gym-goer found dead in swimming pool. (My London, 30 September, 12:52). Available at: https://www.mylondon.news/news/local-news/acton-gym-goer-found-dead-swimming-5981326 accessed 24 March 2020.
Greenwood, C. (2011). City girl’s pool death: did super-fit executive overdo it in gym before suspected heart attack? (Mail Online, 8 December, 22:48). Available at: https://www.dailymail.co.uk/news/article-2071851/Elsa-Carneau-pool-death-Did-executive-overdo-Virgin-Active-gym-heart-attack.html accessed 25 March 2020.
Greenwood, C. (2013). One of Sir Richard Branson’s Virgin Gyms fined £100K over pool death of former model. (Mail Online, 21 December 2013, 11:46). Available at: https://www.dailymail.co.uk/news/article-2527410/One-Sir-Richard-Bransons-Virgin-Gyms-fined-100k-pool-death-former-model.html accessed 24 March 2020.
Horrox, C. (2013a). Virgin Active club fined £100k after model died in swimming pool. (My London, 27 December, 08:55). Available at: https://www.mylondon.news/news/west-london-news/virgin-active-club-fined-100k-6448189 accessed 24 March 2020.
Horrox, C. (2013b). Kensington gym fined £100,000 after models death in swimming pool. (My London, 24 December, 12:12). Available at: https://www.mylondon.news/news/local-news/kensington-gym-fined-100000-after-6445119 accessed 24 March 2020.
Rousewell, D. (2014). Richard Branson’s flagship Virgin Active club criticised by Coroner after pool death of former model. (Mirror, 6 May, 23:33). Available at: https://www.mirror.co.uk/news/uk-news/elsa-carneau-richard-bransons-virgin-3504188 accessed 24 March 2020.
Spear, S. (2014). Virgin Active fined after pool death. (CIEH Environmental Health News, 15 January, 12:00). Available at: http://www.ehn-online.com/news/article.aspx?id=10682&2427Y,B872MS,7MH4Y,1 accessed 24 March 2020.
Stevens, J. (2014). Former lingerie model who drowned in Virgin Active pool was ‘euphoric and exuberant’ and had empty alcohol bottles in her bag, Inquest told. (Mail Online, 28 April 2014). Available at: https://www.dailymail.co.uk/news/article-2615287/Former-lingerie-model-drowned-Virgin-Active-pool-euphoric-exhuberant-alcohol-bottles-bag-inquest-told.html accessed 24 March 2020.
The Times Online. (2014). Gym worker took video of drowning swimmer. (30 April, 01:01). Available at: https://www.thetimes.co.uk/article/gym-worker-took-video-of-drowning-swimmer-fmk9vs3nwjc accessed 24 March 2020.
Webb, S. (2014). Sir Richard Branson’s Virgin Active gym criticised over death of ex-model who drowned in the swimming pool after staff failed to carry out CPR correctly and even FILMED her dying on a mobile phone. (Mail Online, 6 May, 16:49). Available at: https://www.dailymail.co.uk/news/article-2621545/Sir-Richard-Bransons-Virgin-Active-gym-criticised-death-ex-model-drowned-swimming-pool-staff-failed-carry-CPR-correctly-FILMED-dying-mobile-phone.html accessed 24 March 2020.
Citation: Jacklin, D. 2020. Case Summary: Elsa Carneau. Water Incident Research Hub, 10 April.
