Case Summary: Evan Davies
Feb 14, 2021CASE SUMMARY
Evan Davies was four years old when he was taken by his father, Gryffydd Rhys Davies, to Bro Ddyfi Leisure Centre in Machynlleth on Monday, 24 November 2014, for a swimming lesson. Evan was left in the care of the swimming teacher, who was managing a mixed-age swimming group. Near the end of Evan’s swimming lesson, Mr Davies returned to collect his son.
The safety of those in Evan’s swimming lesson was provided for by the swimming teacher, Bethany Byrne and poolside lifeguard, Kai Lewis. The poolside lifeguard was responsible for supervising several swimming lesson groups. On this occasion, that totalled 21 other children (Gedge, 2016).
Evan was part of the “minnows” class. He was a non-swimmer and part of a 30-minute lesson containing eight children (all non-swimmers) supervised by one swimming instructor (Drury, 2016). Near the end of Evan’s swimming lesson, the swimming instructor allowed the children to take part in a three-minute free-play session (Shropshire Star, 2016). Evan got into difficulty and was unable to get to a point of safety. He fell unconscious below the surface of the water.
At the point Evan got into difficulty, the poolside lifeguard had left his station to put lane ropes into the pool for the next lesson, and the other swimming instructors were completing paperwork on the pool surround or in conversation with parents (RoSPA, 2017; Wilkins Safety Group, 2016; Bowers, 2016; Drury, 2016).
As Mr Davies looked for his son in the pool, he spotted him below the surface of the water (BBC News, 2016; RoSPA, 2017; Drury, 2016). Mr Davies immediately shouted to the lifeguard and swimming instructor on the poolside to alert them to his son underwater (BBC News, 2016; Applebey, 2016). At that moment, Evan’s instructor, Miss Byrne, was chatting to fellow instructors Ellen Dawson and Eleanor George and had her back to Evan.
Evan was recovered from the water by his swimming teacher Miss Byrne (Shropshire Star, 2016). Evan was not breathing, and his lips were blue. Staff and a parent, Sonja Rogers, commenced resuscitation and managed to resuscitate Evan (Shropshire Star, 2016). He was transferred by paramedics to Bronglais hospital (BBC News, 2016). Evan made a full recovery in hospital and was able to return home a day later (Croner-I, 2017; Drury, 2016).
Investigation
The Bro Ddyfi Leisure Centre was operated by Powys County Council, and consequently, the HSE led the investigation into the incident immediately following the accident in 2014 (Local Government Lawyer, 2016). In 2016, the HSE concluded its investigation. HSE Inspector Gary Martin said (Local Government Lawyer, 2016; Wilkins Safety Group, 2016; RoSPA, 2017; Bowers, 2016; Shropshire Star, 2016; Drury, 2016; BBC News, 2016; Croner-I, 2017)
Our investigation has found that Powys County Council failed to properly risk assess the swimming lessons and in particular that part of the lesson where mixed abilities and ages were allowed to take part in free play.
The authority had never carried out a risk assessment for the free play periods. The pool alarm button could not be reached by lifeguard Kai Lewis without him climbing down from his highchair and, even when activated, it was not audible on poolside but only in the reception area.
The Council had not defined the position or roles of the staff to supervise free play, failed to deal with the distraction caused by parents coming onto the poolside at the end of lessons and during free play and failed to give adequate time or resource between sessions to reconfigure the pool lane ropes (each session began and finished on the half-hour).
The pool had been well-staffed but those on poolside with responsibility for supervision had allowed themselves to be distracted. Free play for children learning to swim is an important activity in building their confidence in the water. However, the risks of mixing swimmers of limited ability with children who may be older or stronger in the water must be managed correctly.
We are of the view that the council should have taken simple, additional steps that would not have led to a parent’s worst nightmare of finding their child floating unconscious in a swimming pool. Evan is lucky that his father turned up when he did.
Powys Council were charged with a breach of s.3(1) HSWA 1974 and Regulation 3(1) MHSWR 1999 (Croner-I, 2017).
R v Powys County Council (2016) (Unreported, 17th November, Swansea Crown Court)
The case was sent from Swansea Magistrate’s Court to the Swansea Crown Court. Powys County Council appeared at Swansea Crown Court on Thursday, 17 November 2016 and pleaded guilty to breaching s.3(1) HSWA 1974 and Regulation 3(1) MHSWR 1999 (Applebey, 2016; Bowers, 2016; Drury, 2016; Local Government Lawyer, 2016).
Simon Parrington, prosecuting, said (Applebey, 2016; BBC News, 2016; Drury, 2016; Shropshire Star, 2016):
Evan’s father Gryffydd Rhys Davies arrived at the pool to collect him but could not see him amongst other children taking part in a three-minute free play session. He went to the side of the pool where he spotted him lifeless and underwater.
Evan was pulled from the water but he was not breathing and his lips had turned blue. Another parent revived Evan and he was taken to Bronglais hospital. Although Evan was deprived of oxygen, he later made a full recovery.
The play session was to last only a few minutes but it takes seconds for a child to drown. If Evan had been in the water some seconds more the outcome would have been fatal. Evan had not been in the vision of his teacher, Bethany Byrne. Whilst behind her and unseen he went out of his depth and under the water.
How often do we hear I only turned my back for a moment? It was only when Mr Evans observed his son at the bottom of the pool that steps were taken to rescue him.
Richard Lynagh, representing Powys council, said (Drury, 2016):
The Council regrets this incident and implemented changes immediately following the accident. The swimming classes had been running for 14 years without any incident. The authority has co-operated fully with the HSE.
HHJ Geraint Walters said (BBC News, 2016; Applebey, 2016; Drury, 2016; Wilkins Safety Group, 2016; Croner-I, 2017; RoSPA, 2017; Shropshire Star, 2016):
The lack of effective supervision was the main cause of the near tragedy, but there had also been systematic failures in not carrying out a proper risk assessment. The staff took their eye off the ball. The risk had not been addressed at all.
I assess the offending to fall within the £130,000-£750,000 area of the sentencing guidelines. I take into account the authority’s plea of guilty. I also take into account that the authority is publicly funded and any fine is paid from those public funds.
I, therefore, order that the Council pay a fine of £75,000 and £16,000 towards the prosecution costs in addition to the £8,000 already paid during the investigation.
Kelly, who is Mr Davies’ fiancée, said following the hearing (Gedge, 2016):
We are relieved that the Council has been fined for its part in Evan’s accident. Mr Davies and I will always remember how close things were to ending in tragedy, and we hope lessons will be learnt to prevent further incidents.
Thankfully Evan doesn’t appear to remember too much of that night, although I have a feeling it’s because he doesn’t realise how serious things could have been.
However, his father and I will always remember how close we were to losing our boy that night and how lucky Evan is that my fiancé had the instinct that something wasn’t right.
References (13)
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.
Applebey, L. (2016). Father found four-year-old unconscious in swimming lesson, court hears (21st November, 00:00). Available at: https://www.shponline.co.uk/in-court/father-found-four-year-old-unconscious-in-swimming-lesson-court-hears/ accessed 15th January 2021.
BBC News. (2016). Powys council’s £75k fine after boy nearly drowned at pool. (17th November, 00:00). Available at: https://www.bbc.com/news/uk-wales-mid-wales-38019587 accessed 15th January 2021.
Bowers, M. (2016). Council fined after boy almost drowns at public pool. (Bollington, 25th November, 00:00). Available at: https://www.bollington.com/news/public-liability-insurance/council-fined-after-boy-almost-drowns-at-public-pool-213018 accessed 15th January 2021.
Croner-I (2017). Health and Safety Executive v Powys County Council 2016 (18th April, 00:00). Available at: https://app.croneri.co.uk/law-and-guidance/case-reports/health-and-safety-executive-v-powys-county-council-2016-swansea-crown?product=133 accessed 15th January 2021.
Drury, J. (2016). Powys county council fined £75k after child almost drowned at swimming lesson. (Powys County Times, 24th November, 00:00). Available at: https://www.countytimes.co.uk/news/15837052.powys-county-council-fined-75k-after-child-almost-drowned-at-swimming-lesson/ accessed 15th January 2021.
Gedge, A. (2016). We were so close to losing our little boy. (Cambrian News, 23rd November, 00:00). Available at: https://www.cambrian-news.co.uk/article.cfm?id=110537&headline=%27We%20were%20so%20close%20to%20losing%20our%20little%20boy%E2%80%99§ionIs=news&searchyear=2016 accessed 15th January 2021.
HSCS. (2016). Father found four-year-old unconscious in swimming lesson, court hears. (10th December, 00:00). Available at: https://www.hscsscotland.com/father-found-four-year-old-unconscious-in-swimming-lesson-court-hears/ accessed 15th January 2021.
Jeal, W. (2016). Fine for council in near drowning case. (Wiser Safety Management, 23rd November, 00:00). Available at: https://www.wisersafety.co.uk/wiser-safety-management-blog/209-fine-for-council-in-near-drowning-case.html accessed 15th January 2021.
Local Government Lawyer. (2016). Council told to pay £90,000 after boy nearly drowns in swimming lesson. (22nd November, 00:00). Available at: https://www.localgovernmentlawyer.co.uk/litigation-and-enforcement/400-litigation-news/32529-council-told-to-pay-90-000-after-boy-nearly-drowns-in-swimming-lesson accessed 15th January 2021.
Mercury Legal. (2016). Council fined £75,000 after boy nearly drowns (28th November, 00:00). Available at: https://www.compensation.co.uk/resources/news/council-fined-75000-boy-nearly-drowns/ accessed 15th January 2021.
RoSPA (2017). The RoSPA Leisure & Education Journal. (Winter ed.). Available at: http://www.rospa.com/rospaweb/docs/advice-services/leisure-safety/journal/17-winter-2017.pdf accessed 15th January 2021.
Shropshire Star. (2016). Powys county council fined £75,000 after boy 4, almost drowned. (26th November, 00:00). Available at: https://www.shropshirestar.com/news/politics/2016/11/26/powy-county-council-fined-75000-after-boy-4-almost-drowned/ accessed 15th January 2021.
Wilkins Safety Group. (2016). Council fined after boy nearly drowns (30th November, 00:00). Available at: https://wilkinssafety.co.uk/2016/11/council-fined-boy-nearly-drowns/ accessed 15th January 2021.
Citation: Jacklin, D. 2021. Case Summary: Evan Davies. Water Incident Research Hub, 14 February.
