Case Summary: Vanessa Gregson and Tshan Kamara
Feb 28, 2021CASE SUMMARY
Tshan Kamara was seven years old when she, along with four other children from two families, were on holiday at the Honicombe Manor Holiday Park, St Anns Chapel, Callington, Cornwall.
On Thursday, 20 May 1999, the five children, including Tshan, were taken to use the indoor swimming pool by 19-year-old Vanessa Gregson (Birmingham Post, 2000). Tshan's father Darren Kamara, and his companion Marcie Jackson had returned home to Liverpool the previous day, and Vanessa was left in charge of the five children. Mr Kamara and Ms Jackson were expected back at the holiday village the following day (Friday 21st May) (Birmingham Post, 2000). Vanessa was a family friend of Tshan’s family and had been working recently as a nursery assistant.
Tshan was a non-swimmer. Vanessa was a competent swimmer. There were no lifeguards on the poolside. During the swim, Tshan climbed onto Vanessa’s shoulders whilst they were in the pool. Vanessa slipped on a steep slope at the bottom of the pool and banged her head, rendering herself unconscious in the water (Mirror, 2000; Lee, 2000). Tshan was unable to get herself to safety. Both Tshan and Vanessa were underwater for 10 minutes before some of the other four children raised concerns with the pool staff (The Caterer, 2000; Birmingham Post, 2000).
Vanessa and Tshan were both taken by Cornwall Air Ambulance to Derriford Hospital. Vanessa was pronounced dead shortly after her arrival at the hospital. Tshan however continued to be in a critical condition for some time. Mr Kamara was contacted during the night by Merseyside Police and immediately drove to Derriford Hospital to be at Tshan’s bedside (BBC News, 1999; Allen, 1999).
Tshan had suffered extensive brain damage, and her parents, Darren Kamara and Sharon Wong, agreed to her life support system being switched off on Saturday evening, two days after she was admitted to hospital (Birmingham Post, 2000; Lee, 2000; Mirror, 2000).
Coroner’s Inquest (2000) (Bodmin Coroner’s Court, 7th January)
Coroner Dr Bruce heard a joint inquest into the death of Vanessa Gregson and Tshan Kamara at Bodmin Coroner's Court on the 7th of January 2000.
The inquest was told that initial reports of the circumstances leading to the accident were mixed. Some reports were that Tshan had fallen into the deep end before getting into difficulty (Birmingham Post, 2000; Allen, 1999). Others described that Tshan had gotten her hair trapped in a pool inlet and Vanessa had drowned trying to save her (Lee, 2000; BBC News, 1999). There were no witnesses to the circumstances which led to the two girls drowning. The inquest concluded that it was more likely than not that Tshan had been riding on Vanessa's shoulders when Vanessa lost her foot on the deep slope, and the two became locked, drowning each other in the process (a well-established aetiology for double drowning incidents called “locked swimmers”).
Home Office pathologist Dr Guyan Fernando said (Birmingham Post, 2000):
Ms Gregson had a bruise on top of her head and it was possible she had hit her head on the side or bottom of the pool. Ms Gregson drowned and Tshan died two days later at Derriford Hospital as a result of drowning. There was evidence of cannabis in Ms Gregson's system but this was unlikely to have been affecting her at the time.
Mr Martin Thompson, a trained St John Ambulance first-aider, told the inquest that he saw separate incidents in which two children nearly drowned within an hour of each other at the same pool in 1996 (Birmingham Post, 2000).
West Country Ambulance Service spokesman Chris Wiseman told the inquest (BBC News, 1999):
The first report we received were that the girls were in the water for at least 10 minutes. What we got from one of the flight paramedics is the youngster was in there first and got trapped. The paramedics involved have been traumatised by the tragedy.
PC Anthony Shergold of the Devon and Cornwall Police Underwater Search Unit said (Birmingham Post, 2000):
An adult carrying a child would probably lose their footing walking on the gradient towards the deep end. In my opinion there should have been a lifeguard.
The authority's principal environmental health officer, Mr Nigel Ramsey, told the inquest (Birmingham Post, 2000):
The holiday village only had lifeguards on duty during busy times of the year. Caradon District Council had inspected the pool in 1996 and 1998 and recommended improvements, including a pool alarm and depth markings. It had not recommended lifeguards.
I had not personally carried out any inspection of the site, but it is my view there should have been a lifeguard. However, recommendations from the authority do not have statutory force.
Mr Mike Vernon, who owned and operated Honicombe Manor Holiday Park for the last 10 years, said:
I did not know the 19-year-old had been left in charge of so many children. The member of staff who pulled the two girls from the water is still in a state of shock.
Recording a verdict of accidental death in relation to Vanessa and Tshan’s deaths, Coroner Dr Bruce said (Birmingham Post, 2000; Mirror, 2000):
On the balance of probabilities, I agree with Dr Fernando that Ms Gregson likely lost her footing at the point of change of gradient whilst Tshan was on her shoulders. Ms Gregson hit her head and fell unconscious, resulting in Tshan, a non-swimmer, being left unable to reach a point of safety from their position in the deep end of the pool. Both were unattended to for over 10 minutes.
I find it almost incredible that a hazard such as the gradient should be allowed in a pool to which holidaymakers had access. There had been at least four deep end incidents in the pool since 1992 and before these two deaths. There was no written safety policy or emergency action plan for the pool complex.
The recommendations on pool safety made by Caradon Council before the May incident were not acted on. The council itself had failed to identify the very serious hazard of the pool gradient. If this danger had been taken into account, it is difficult to believe the inspecting officer would not have made a recommendation for a lifeguard.
There had been several potential fatalities at the pool. These included an incident in which a seven-year-old boy who had been left alone was rescued by a member of staff. On another occasion, a swimmer with learning disabilities was rescued from the deep end by a lifeguard who was on duty.
I accept there is no system of licensing holiday industry pools at present but had there been a competent and watchful lifeguard there is every likelihood, he or she would have been able to save at least one if not both lives. It is my view that pools at such camps should also be licensed.
I propose to write to the appropriate authority to make suggestions in relation to pools and expert inspection of pools in the hope there may be a prospect of eliminating those pools with unsafe design, unsatisfactory maintenance and slack operating procedures. I include within that note my view that the pool be shut until the hazardous slope in the deep end is changed.
Investigation
In a statement prior to the Coroner’s inquest, the police and council said (Lee, 2000; The Caterer, 2000; Birmingham Post, 2000; BBC News, 1999; Allen, 1999).
Our joint investigations are continuing. The pool was immediately shut while forensic experts and health and safety officials from Caradon District Council carried out investigations. The council served an improvement notice on the centre owner Mr Vernon the day after the incident, regarding safety floats, depth markings and emergency alarm systems. He has been given 21 days to comply.
An investigation into this sort of incident will take into account the level of risk to the public. The council does have powers, if appropriate, to prosecute. Given that there has been loss of life in this case we shall be pursuing the matter thoroughly but sensitively.
Police divers have examined the pool and circular swimming areas joined by a channel. Early indications that the victims were trapped by their hair in a filtration grille have been ruled out. Police have interviewed other children present at the scene of the incident to try to discover what happened.
We are still collecting evidence and any prosecution cannot be ruled out at this stage.
After the inquest, Ms Gregson’s mother, Cheryl Gregson, said (Birmingham Post, 2000; The Caterer, 2000):
I support the coroner's call for a proper licensing system. The local authority seemed disorganised and to have fallen down on its job.
I am suing the owners of Honicombe Manor Holiday Park for compensation arising from the deficiencies which led to the loss of my daughter Vanessa.
No sources of information in the public domain have confirmed whether this claim was issued and, if it was, whether it was successful.
Following the conclusion of the Coroner’s inquest on the 8th of January 2000, Caradon Council served a prohibition notice on the Holiday Village preventing the pool from being operated until the condition of the pool and its supervision were addressed (Birmingham Post, 2000). It said:
We strongly support the recommendation of the coroner that holiday swimming pools should be subject to statutory licensing. We are now looking to make an early decision on whether to bring a prosecution in this case.
R v Mike Vernon (2000) (Unreported, 13th April)
Caradon District Council brought a prosecution against Mr Mike Vernon in 2000. Karen Trickey, legal services manager for the council, said (Sheppard, 2000):
Although the two fatalities are not unconnected, what we are prosecuting are the breaches of health and safety legislation. Owners have a duty of care to look after members of the public using their premises.
Mr Vernon appeared at the Magistrate’s Court charged with four counts of breaches relating to the HSWA 1974 on 13th April 2000. No sources of information in the public domain have confirmed the outcome of this case.
House of Commons (2000) (Westminster Hall, private swimming pools, 18th January)
Mr Colin Breed said:
Last summer, at Honicombe Manor holiday park, near Callington in my constituency, two young girls tragically drowned in the privately owned swimming pool at the holiday centre. The coroner's report, issued two weeks ago, was most distressing because it revealed that, had the pool complied with the guidelines set out by the Health and Safety Executive, the deaths could have been avoided. The pool was not supervised by a lifeguard; there was no emergency alarm or poolside telephone; and the pool shelved rapidly to a deep section that was not properly signposted. All those factors go against the guidelines and recommendations set out in "Managing Health and Safety in Swimming Pools--a document recently updated by the Health and Safety Executive and the Sports Council of England, which I wholeheartedly commend and endorse.
I bring the matter to the House of Commons today in the hope that something can be done to ensure that accidents such as that latest tragedy do not happen again. The problem with private swimming pools--for the purposes of our debate, I mean pools in hotels, camp sites, self-catering complexes and similar establishments, but not domestic pools--is that they are not subject to the demands of specific regulations. They need comply only with the provisions of the Health and Safety at Work, etc. Act 1974, which states that their owners should accept a duty of care. As I said, guidelines exist on how to do that; they are good and comprehensive, but they are little more than suggestions of how best to meet the health and safety at work regulations. They contain few specific requirements and, if the guidelines are not heeded, pool owners and operators face little threat of disadvantage.
Local authorities have the power to issue orders for improvement, or prohibition orders. However, as illustrated by the case in my constituency, those orders are not always heeded, and the system of checks is not as rigorous as necessary. In light of the number of accidents that have occurred in such facilities, that cannot be allowed to continue.
The coroner at the inquest in the Honicombe Manor case has, in recent years, presided over inquests into seven deaths in holiday industry pools in Cornwall. Statistics prepared by the Royal Society for the Prevention of Accidents show that the number of drownings in private pools has been worryingly high for a number of years. Of most concern is the fact that, although the number of accidents in public pools has fallen, the number of accidents in private pools has not. In 1998, the number of deaths in private pools was more than double the number of deaths in public pools. That illustrates the fact that, if the new guidelines were rigorously enforced in private pools, as they are in municipal pools, lives would be saved.
Surely it is time to take the advice of the coroner, who said that there is no system of licensing of holiday pools and there is because of the wide range of other duties a limited expertise available to the inspecting authority. He recommended the introduction of a licence for pools to be granted or withdrawn on satisfactory inspection of the implementation of guidelines. I understand that he has written to the Government and, in the light of his experience, I hope that his words will be heeded.
…We want our children to learn to swim and to become strong swimmers by swimming regularly, and pools are the safest places for them to do that. However, they are safe only if the pools are properly supervised, if there are clear markings to show where unconfident swimmers can swim within their depth and if there is a clear action plan for when things go wrong, as they sometimes do, albeit rarely. We must also remember that many schools use local private pools for swimming lessons.
The fact that other swimming areas are more dangerous is no excuse for inaction. I fully accept that there will always be risks attached to leisure pursuits involving water. Simple, relatively inexpensive precautions should be taken, however, to ensure greater safety in private swimming pools.
The guidelines issued by the Health and Safety Executive are extremely well thought out. Although they recognise that not all swimming pools will meet top standards at all times, they give clear, sensible guidance on how to minimise risk. We must ensure that the guidelines are properly implemented. Had they been, I am certain that there would not have been a pool with a sharp and badly signposted shelf to a deep section, no poolside alarm and no lifeguard, although not all those might have been realistically available while a small holiday business maintained commercial viability. Had the recommended system been in place, however, the pool would not have been granted a licence until a least its gradient had been lowered and a trained and qualified specialist health and safety inspector had outlined and approved a clear emergency plan.
Several problems relate specifically to swimming pools. We are all aware that swimming pool design and installation differ from what existed a few years ago. We are aware of recent cases in which hair has been trapped in filter systems, injuries have resulted from poorly designed water slides and flumes, and accidents have been caused by poor layout such as low-level overhead pipes. We have also heard about more common problems, such as the bad signage of deep areas, sharp shelves into deep water and slippery poolside surfaces. We need properly qualified people who are trained specifically to spot those potential problems and enforce recommendations at the design stage and when the pool is commissioned for use. Such a regime would not be difficult to implement. Existing environmental health officers need to be qualified in the specialist subject of swimming pool safety.
House of Commons (2000) (Westminster Hall, Health and Safety Executive, 17th May)
Mrs Louise Ellman (Liverpool, Riverside) said:
I, too, commend the report because of the renewed attention it brings to the issue of health and safety. I commend it also because of the stress it lays on the importance of prevention and responsibility. I support the recommendation that there should be a crime of corporate killing, and the sooner such a measure is introduced, the better.
The report draws attention to the key and successful role played by the tripartite structure of employers, employees and others including local authorities and the public. This morning, I shall draw attention to a failing in that other section, which relates to the responsibility to consider the health and safety of those not directly employed in the workplace and to the role of a local authority as an agent of the Health and Safety Executive.
I wish to draw attention to tragic circumstances in which the system failed. On 20 May 1999, two of my constituents--Vanessa Gregson aged 19 and a strong swimmer, and Tshan Kamara aged seven--were found drowned at the deep end of an unsupervised swimming pool at Honicombe Manor holiday park in Cornwall.
…Such a tragic circumstance raises several key issues relating to health and safety. I have raised the incident with the director-general of the HSE. In a letter that I received from her on 16 March, I was told:
If swimming pool operators follow the guidance given, they will be well placed to prevent unnecessary injuries and fatalities to pool users... As part of a routine programme, we regularly review all guidance to ensure the best possible advice is available... We shall be reviewing the guidance for swimming pool operators again in the near future. I hope that the HSE will indeed review its guidance to ensure that it is effective. I also hope that, in doing so, it examines the implementation of the guidance more closely and assesses the expertise of those whose remit is to implement it. I hope, too, that it will look beyond its current guidelines. It and the Government must examine the issue of statutory licensing of pools that are used by the public. It is not good enough to be told, as I was by the director-general of the HSE, that because it is more dangerous to swim in the sea than it is in a private swimming pool, we do not need to secure closer regulation of such pools.
My constituents died in tragic circumstances; two young lives were lost needlessly. The prosecution, which starts today, will reach its conclusion on that specific instance. However, I want the HSE to examine the general guidelines more closely to ascertain whether they are adequate and whether there should be greater follow-up and greater strength in the law to enforce them.
The Minister for the Environment, Mr Michael Meacher, said:
...My Hon. Friend the Member for Liverpool, Riverside (Mrs Ellman) mentioned the tragic deaths of two young people in a swimming pool at a holiday site. The matter is now the subject of a prosecution and we shall watch carefully to see how the case unfolds. She asked about statutory licensing, and, again, I undertake to examine the issue further and, if necessary, to reply to her in writing.
References (12)
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.
Allen, N. (1999). Safety shake-up after girl dies in pool rescue bid. (Independent Ireland, 22nd May, 12:11). Available at: https://www.independent.ie/world-news/safety-shake-up-after-girl-dies-in-pool-rescue-bid-26150898.html accessed 2nd February 2021.
BBC News. (1999). Safety moves follow pool tragedy. (22nd May, 06:54). Available at: http://news.bbc.co.uk/1/hi/uk/349134.stm accessed 2nd February 2021.
Birmingham Post. (2000). Holiday pool to shut after drowning tragedy. (8th January, 00:00). Available at: https://www.thefreelibrary.com/Holiday+pool+to+shut+after+drowning+tragedy.-a060504864 accessed 2nd February 2021.
Birmingham Post. (2000). Pool where girls drowned had history of near-fatal accidents. (7th January, 00:00). Available at: https://www.thefreelibrary.com/Pool+where+girls+drowned+had+%27history+of+near-fatal+accidents%27.-a060504429 accessed 2nd February 2021.
Birmingham Post. (2000). Swimming pool tragedy of teenager and toddler. (6th January, 00:00). Available at: https://www.thefreelibrary.com/Swimming+pool+tragedy+of+teenager+and+toddler.-a060504085 accessed 2nd February 2021.
Lee, K. (2000). Pool tragedy adds to Cornwall’s death tool. (The Caterer, 1st January, 00:00). Available at: https://www.thecaterer.com/archive/pool-tragedy-adds-to-cornwalls-death-toll accessed 2nd February 2021.
Mirror. (2000). Girls died in danger pool. (8th January, 00:00). Available at: https://www.thefreelibrary.com/Girls+died+in+danger+pool.-a060281650 accessed 2nd February 2021.
Sheppard, G. (2000). Swimming pool deaths under spotlight again. (The Caterer, 13th April). Accessed https://www.thecaterer.com/archive/swimming-pool-deaths-under-spotlight-again accessed 2nd February 2021.
The Caterer. (2000). Mother seeks compensation after holiday park drowning. (3rd February). Available at: https://www.thecaterer.com/archive/mother-seeks-compensation-after-holiday-park-drowning accessed 2nd February 2021.
The Caterer. (2000). Probe into pool deaths goes on. (1st January, 00:00). Available at: https://www.thecaterer.com/archive/probe-into-pool-deaths-goes-on accessed 2nd February 2021.
UK Parliament. (2000). Health and Safety Executive. (17th May, 09:30). Available at: https://publications.parliament.uk/pa/cm199900/cmhansrd/vo000517/halltext/00517h01.htm accessed 2nd February 2021.
UK Parliament. (2000). Private swimming pools. (18th January, 11:30). Available at: https://publications.parliament.uk/pa/cm199900/cmhansrd/vo000118/halltext/00118h02.htm accessed 2nd February 2021.
Citation: Jacklin, D. 2021. Case Summary: Vanessa Gregson and Tshan Kamara. Water Incident Research Hub, 28 February.
