Case Summary: Jane Bell

CASE SUMMARY

Jane Bell was 3 years old and from Galashiels, Scotland, when she went on holiday to the seafront Dalmeny Hotel at St Anne's, Lancashire, in August 2014 with her parents, Sarah and David Bell. The Dalmeny Hotel was a family-run independent enterprise with a swimming pool on the premises.

The Bell family arrived at the Hotel and attended the swimming pool on the morning of Thursday, 14 August 2014. The swimming pool, like many hotel pools in the UK, had been assessed to provide constant poolside supervision by means of a CCTV camera over the swimming pool in place of a physical lifeguard presence on the poolside. This was then supplemented by physical checks of the poolside by staff at a periodic interval as defined in the Hotel operating procedures based on its risk assessment. Jane on the day was not wearing or using any buoyancy or swimming aids whilst in the water.

The family, including Jane, were enjoying the pool when shortly prior to 11:00, Sarah Bell was unable to support Jane in the water, and she sank to the bottom of the 2.3-metre-deep end. Efforts were made by Sarah and David Bell to recover Jane from the bottom but were unable to dive to the required depth to recover Jane to the surface. A customer in the changing room, Ms Carole Greenwood, who also happened to be a lifeguard and swimming teacher but who did not work at this Hotel, was the first to respond to cries for help. 

Ms Greenwood was able to recover Jane from the swimming pool bottom and CPR was commenced. Staff from the hotel supported efforts to resuscitate Jane and to summon assistance from the emergency services. Paramedics arrived and continued to work to resuscitate Jane before transferring her, firstly to Blackpool Victoria Hospital, the nearest Accident and Emergency Department, before complications in Jane’s condition led her to be transferred to Royal Manchester Children’s Hospital, one of the leading paediatric hospitals in the North of England.

After three cardiac arrests following the drowning, Jane was pronounced dead by the team at Royal Manchester Children’s Hospital (Caven, 2014).

Pre-Inquest Investigation

Officers got the call just before 11:00 on Thursday that a child had drowned (Herald, 2014). Police attended the Dalmeny Hotel in accordance with standard protocol following a death. Initial reports of the incident were very mixed. At a very early stage, the investigating officer decided to arrest Mrs Bell on suspicion of murder. Officers made the decision based on the evidence they had received at the time of arrest that Jane’s parents had failed to initiate Jane’s rescue or summon emergency assistance. This was later found to be incorrect. For context, in cases of death in the workplace, an arrest for suspicion of murder is rare.

Detective Inspector Nick Connaughton said that investigations were still at an early stage but that they had arrested a 40-year-old woman from Galashiels. He said:

This is a terribly tragic situation where a young girl has lost her fight for life after an incident in a hotel swimming pool. We are now treating this sad case as murder and need to know just how the child has come into difficulties in the pool.

Explanatory notes on charging decisions

This is a highly irregular decision by the Police, and it is worth taking a few moments to explain what is going on before returning to Jane’s story. The Crown Prosecution Service, independent of the Police, is the responsible decision-making body for whether an individual is charged with a criminal offence. The Police present the evidence they have collected, and the CPS make a decision whether the Full Code Test in the Code for Crown Prosecutors is satisfied. The Full Code Test should be applied when all outstanding reasonable lines of inquiry have been pursued or the prosecutor is satisfied that any further evidence or material subsequently obtained is unlikely to affect the Full Code Test in favour or against prosecution. There are two stages to the Full Code Test:

The Evidential Test (CCP, 4.6-4.8)

Prosecutors must be satisfied that there is sufficient evidence to provide a realistic prospect of conviction on each charge’ assessed by the Prosecutor’s objective assessment of the evidence presented. It means that a jury must be more likely than not (balance of probabilities) to convict, which is lower than the criminal standard that is required for a conviction in a criminal court. Whether than evidence is admissible, reliable, credible and sufficient is key to that assessment.

The Public Interest Test (CCP, 4.9-4.14)

A Prosecution will normally take place unless public interest factors outweigh those in favour of the prosecution. Paragraph 4.14 (a)-(g) set out a non-exhaustive list of factors Prosecutors should take into account when assessing the public interest test; the weight of each factor varying on a case-by-case basis according to the merits of the evidence. Factors included, seriousness, culpability, circumstances of harm caused, suspect’s age/maturity (under 18), impact on the community, proportionate response, sources of information that require protection.

The Five Conditions of the Threshold Test (CCP, 5.1-5.11)

In limited circumstances where both limbs of the Full Code Test are not met, the five conditions of the Threshold Test may be used to base a charge on a suspect. These include:

• Reasonable grounds to suspect that the person to be charged committed the offence based on admissible, reliable and credible evidence.
• Further evidence can be obtained to provide a realistic prospect of conviction that has been identified and is not merely speculative.
• Seriousness or circumstances of the case justify the making of an immediate charging decision (the urgency ground).
• Continuing substantial grounds to object to bail in accordance with the Bail Act 1976 and in all circumstances of the case, it is proper to do so (e.g. serious risk of harm to the public, serious risk of absconding or interfering with witnesses or evidence).
• It is in the public interest to charge the suspect.

Any decision to charge under the Threshold Test must be kept under constant review.

After careful application of the test by the CPS, which would have also considered a reduction of the charge to manslaughter which we have seen charged in other swimming pool cases against parents, the decision of the CPS was to bring no charges against Mrs Bell. The reviewing Prosecutor, Ms Joanna White, said (as reported by BBC, 2014):

I have carefully considered all the material submitted, including a number of witness statements and CCTV footage from the hotel, and I have concluded that there should be no criminal proceedings against her in connection with the death. An inquest will now follow. No further action will be taken against Mrs Bell.

Detective Chief Inspector Dean Holden said:

The Police investigation is now closed and we will provide the Coroner with all the relevant information for the inquest.

The Police role in fatalities such as this is to investigate any potential charges for manslaughter. If they are satisfied there is not sufficient evidence for manslaughter against a company or individual, then it will hand any evidence it has collected to the health and safety enforcing authority, which in this case was the Environmental Health team at Fylde Borough Council.

 

The coronial inquest into the death of Jane Bell (2014) (Blackpool Town Hall, unreported)

The inquest into Jane’s death was held at Blackpool Town Hall by Coroner Alan Wilson. Jane’s parents Sarah and David Bell chose not to attend the inquest (Caven, 2014). The Coroner noted that:

It is somewhat unusual that the mother and father have chosen not to attend the inquest.

The Inquest was told by the family GP has said that following the death of their daughter, Mr Bell had suffered from depression and Mrs Bell had suffered a ‘pathological degree of shyness’. The circumstances of Mrs Bell’s arrest and release without charge for the murder of her daughter shortly following Jane’s death cannot have assisted her parents in coming to terms with her death.

The inquest heard that the pool had signage in place around the pool area which included advice for swimmers about the pool depth and that only competent swimmers should go past a certain point. The pool had CCTV cameras in a place visible from the Reception desk. The inquest was told, that on the morning of the incident, a member of staff spent 90 minutes working alone at reception and was expected to undertake other duties and was therefore unable to constantly view the pool area. The pool did not provide staff on the poolside.

Another witness told the inquest he used the swimming pool at the hotel regularly and had seen the staff blow their whistle and be generally visible during float time. He said he had been made aware of the signage and the need to supervise young children. The Hotel explained that it had approximately 33,000 guests per year and had operated for over ten years without a single incident of this kind.

Mr Mills, who provided expert evidence to the inquest, said the pool had either to provide a lifeguard or remove the steep slope. Relying on HSG179 version 3, Mr Mills stated HSE guidance (HSG179:2003) provides that swimming pools of this type and depth should provide poolside lifeguard supervision. If the pool depth was reduced to the level set out in HSG 179, the pool could continue to provide supervision by CCTV but would need to support that control with periodic, physical poolside checks by staff. The inquest heard how the hotel currently performed physical poolside checks every 15-60 minutes depending on the conditions. Mr Mills said that was insufficient and the Coroner agreed. The coroner suggested that CCTV and physical checks at 5-minute intervals would have been sufficient, pointing out that two minutes underwater, in this case, had been fatal to Jane Bell.

The inquest also heard distressing details of her parent's failed attempts to rescue their daughter from the pool. The family were enjoying a swim when both parents can be seen on CCTV appearing to leave Jane alone as she swam from the deep end to the shallow end and back again without swimming aids. She is seen halfway down the pool hanging onto the poolside and, at one stage, appears to be beckoning her mother. When it becomes clear she is in trouble, Mr Bell unable to reach Jane due to the 2.3-metre depth, tried to use a long-handled pool net in a desperate attempt to rescue his daughter (Sun, 2016). The inquest heard how a member of leisure staff, who had received no pool rescue training, and who worked in reception, dived down to rescue Jane but was unable to reach her. Jane remained under the water for almost two minutes before Carole Greenwood dived in and brought her to the surface.

Carole Greenwood told the inquest (Caven, 2014):

A lady came in to the changing room where I was changing and said ‘there’s an incident in the pool, is there a life guard?’ The girl I now know to be Jane was at the bottom of the pool. I wasn’t really aware of what had happened when I got there, my concern was with the little girl and rescuing her and resuscitating her as best I could as per my training. She was unresponsive but I did manage to resuscitate her, and she was breathing when the ambulance arrived. I’m devastated for the poor little girl, it’s very sad. At the time you are quite shocked because all your training is coming into action something you think you will never ever do but I’m satisfied I helped out in this case. 

Efforts to rescue Jane were further delayed because there was no lifeguard or member of staff with pool rescue training on shift at the hotel on the day (Graham, 2014a). One staff member dived repeatedly to reach Jane but was unable to do so because of the depth of the pool (Graham, 2014a). Assisted by hotel guest Carole Greenwood, Jane was recovered to the poolside and efforts to resuscitate her began. An off-duty paramedic, Mr James Pendlebury, who was present at the hotel assisted the resuscitation on the poolside. The incident and resuscitation were recorded on the poolside CCTV cameras designed to assist staff to monitor the safety of pool users from the reception desk monitors.

Jane regained consciousness several times but continued to experience complications that would see her suffer three further cardiac arrests before her death at Royal Manchester Children’s Hospital hours later. This pattern of repeated cardiac arrests following drowning events in under 5s has been anecdotally reported by experts and clinicians for over two decades. The specialist care required by such cases most likely prompted the transfer to Royal Manchester Children’s Hospital.

The inquest heard there was no trained lifeguard on duty in the building at the time of the accident. Mr Mills, who provided expert evidence to the inquest, explained that “cameras don’t save lives and rescue people”. Staff on duty had been given no training on how to respond to an emergency in the pool. One staff member dived to reach Jane but could not reach her. Guest Carole Greenwood, a trained swimming instructor, got Jane to the poolside. The inquest was shown CCTV footage of the incident which included footage of off-duty paramedic James Pendlebury and another guest trying to resuscitate Jane (Graham, 2014a). Jane initially regained consciousness but had further cardiac arrests before being pronounced dead at the Royal Manchester Children’s Hospital at 19:55 the same day.

Leisure centre manager Tom Bird told the hearing that the Hotel’s safety practices were dealt with by an outside consultancy (BBC 2016). The inquest heard that staff had received no emergency response training. He said they introduced emergency response training for staff two months after the drowning (Graham, 2014a).

The coroner returned a verdict of accidental death. The cause of her death is that she suffered three cardiac arrests prior to dying. Hotel director Samantha Lewis admitted that the pool’s age made it too deep for modern safety standards and that the hotel was taking new advice and considering installing a false bottom (Spear, 2016). Samantha Lewis, Hotel Director, told the inquest:

We have had quotes from two contractors and hope the work might start later this year. It would bring the pool to the standard required if the pool was being built now.

Councillor Ben Aitken said (Spear, 2016):

This is a tragic and untimely death that should never have happened. Members of the public using swimming pools have the expectation that businesses have the right people and procedures in place to ensure their entitlement to safe swimming. Our sympathy goes to Jane’s family.

 

The issue of Regulation 28 "Prevention of Future Deaths Report"

The Coroner has the power under the Coroners and Justice Act 2009, paragraph 7, schedule 5 as amended by The Coroners (Investigations) Regulations 2013, regulation 28 to issue what is called in general terms a Regulation 28 Prevention of Future Deaths Order. The Coroner made that report in this case. The Coroner said this was justified by the lack of focus on the welfare of people using the pool at the time and that he would be writing to the pool owners, the Chief Coroner and Fylde Council and Jane’s parents (BBC 2016). 

The Prevention of Future deaths report made the following findings:

(a) The inquest heard expert evidence that the requirement for constant supervision can be met with a combination of other factors notably poolside patrol and CCTV monitoring, but I am concerned that the way in which this is to be delivered is insufficient and the duty to write this report is satisfied.

(b) There are now two members of staff employed in the reception area at all time when the pool is open to swimmers. However, the proposed pool side patrol is to be undertaken at sometimes of the day at 15-minute intervals, at other times when swimmer numbers may be lower these patrols may take place less often and up to a minimum of once per hour.

(c) The Inquest heard that a leisure assistant was responsible for monitoring the CCTV at reception he was also required to undertake other duties such as booking guests into the gym distributing towels etc. The Managing Director has now allocated two staff to reception. I do not find this argument convincing to the extent that I am satisfied that the duty upon me to write this report is not met. The expert witness told the inquest that he was ‘not a big fan’ of CCTV and it appears to me that even with two other members of staff, given the other tasks they must also complete it is unlikely that between them the two members of staff will always have the pool in their sight at all times.

(d) This is concerning when considered in combination with proposed pool side patrols. If it were envisaged that patrols be undertaken at 5-minute intervals throughout when children would be swimming then this may cover the few moments that staff observing the CCTV would be distracted from observing the CCTV. However, if such patrols are less frequent, the chances of staff performing those patrols are diluted.

(e) A problem arises if that family is allowing a child to swim alone or in the deeper half of the pool or without floatation aids when they need one. It would also be a problem if the family are not safety conscious, unaware that there is no constant supervision, have over-estimated their child’s swimming ability and paid insufficient attention to the pool signage as a result, or are not complying with the hotel regulations for whatever reason.

(f) Jane Bell was under the water for slightly less than two minutes and this proved fatal. I am concerned that reception desk staff may be distracted for a similar time leaving them unable, in spite of the encouraging work that has been undertaken since this facility to train leisure and entertainment staff in first aid and poolside rescue which the expert witness felt ought to enable staff to effect a pool rescue to prevent a similar fatality. The time needed to assist a child under the water is limited and poolside safety equipment at the hotel is limited to devices that may be used to assist someone struggling on the surface but not necessarily a child under the water.

(g) Hotel management felt there was a marked difference between time of high pool occupancy and other times when the pool is used much less. The concern about future deaths does not arise in respect of times when the pool is empty or when only adults are using it. The concern arises when perhaps only one or two families are using the pool. The evidence provided suggests that poolside patrols would take place much less often than at 15-minute intervals and I am concerned that more infrequent patrols would not satisfy the requirement for constant supervision. Mr Mills stated that he was of the opinion that patrols ought to be conducted at 5-minute intervals.

 

Post-Inquest Investigation

Following the Coronial Inquest and the Regulation 28 Report, the Environmental Health Department from Fylde Borough Council were responsible for investigating the case (Spear, 2016). The case was taken by the EHO’s at Fylde Borough Council to the Crown Prosecution Service who approved the decision to prosecute the Dalmeny Hotel for Jane’s death.

 

R v Dalmeny Hotel Limited [2016] (Preston Crown Court, August, unreported)

The case of R v Dalmeny Hotel Limited was first heard at the Magistrates Court. The Dalmeny Hotel was charged with one count of a breach of s.3(1) HSWA 1974 for failing to ensure, so far as is reasonably practicable, that members of the public were not exposed to risks to their health or safety. The Hotel was also charged with one count of a breach of Regulation 3(1) MHSWR 1999 for failing to make a suitable and sufficient risk assessment of the risks to members of the public arising out of the provision of the commercial swimming pool (Spear, 2016).

Attending the Magistrate’s Court, Mr Bell said:

The hearing today coincides with what should have been Jane’s sixth birthday, and instead of being a day of celebration and happiness, we find ourselves mourning the loss of someone so precious to us. The images of standing at Jane’s bed, watching helplessly as a team of doctors and nurses fight to save her life, are ones that will haunt me forever. I can still see Jane lying on the bed. 

Dalmeny Hotel pleaded guilty to both charges at the Magistrates Court. The Magistrates Court felt their sentencing powers were insufficient and committed the case for sentence to Preston Crown Court in August 2016. It is standard practice in the event of a guilty plea before trial to hold a Newton hearing to determine the key facts relevant to sentencing.

At that hearing, the court heard that Jane had been sitting at the pool’s deep end while her mother, Sarah, had been swimming lengths. Her mother then trod water with Jane, when Jane slipped through her hands and sank to the bottom of the pool. Mr Bell, along with a member of staff, tried to rescue Jane but failed because they couldn’t descend to the 2.3-metre depth (BBC, 2016). A swimmer teacher, later identified as Carole Greenwood eventually got Jane out (Spear, 2016). Attempts were made by an off-duty paramedic and members of staff to resuscitate Jane who was resuscitated several times but died shortly after being transferred to the Royal Manchester Children’s Hospital (Spear, 2016).

The court also heard expert opinion evidence from Mr Peter Mills who was instructed by the enforcement authority, Fylde Borough Council who explained the supervision measures in place did not meet industry standards for a swimming pool with a 2.3-metre deep end (QLM 2016).

At the sentencing hearing at Preston Crown Court in August 2016, The Honourable Recorder of Preston, HHJ Mark Brown, said:

This is a very tragic accident involving the death of a young child in the early years of her life. The defendant must take significant responsibility for what happened. The accident should be an important warning to parents about the dangers of swimming pools and just how easily a young child can drown. At the very least, Jane should have been wearing buoyancy protection when she entered the water and she should never have been allowed to go into the deep end alone. She was only three-years-old.

HHJ Brown fined Dalmeny Hotel £100,000 and in addition the prosecution costs of £19,724.68.

The Bell family contacted the RLSS UK, the UK’s Drowning Prevention Charity, for support after the death of their daughter Jane and throughout the hearings. Following the sentencing hearing, Martin Symcox, Director of RLSS UK, made a statement aimed at ensuring the lessons for operators for taken to prevent future deaths in swimming pools:

Although we would recommend the best course of action is to provide a lifeguarded pool at all times, it is common for hotels and spas not to provide constant poolside supervision. However, as this tragic incident shows, it is crucial that operators make their pools as safe as possible and there are steps operators can take to minimise risks. As a starting point, operators need to conduct a risk assessment to determine the dangers in their pool, who may be harmed, how likely an accident could occur and the measures they could take to reduce or prevent an accident. This risk assessment should be reviewed regularly.

 

References (20)

_{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.} 

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_{BBC News (2016). Jane Bell pool death: Dalmeny hotel owners face trial. (BBC News, 11 July) Available at: https://www.bbc.co.uk/news/uk-england-lancashire-36750861 accessed on 15 April 2020.}

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_{Caven, B. (2014). Police ‘arrest mother on suspicion of murder’ after girl, three, drowns in seafront hotel pool while on holiday with her family. (Mail Online, 15 August, 01:14). Available at: https://www.dailymail.co.uk/news/article-2725490/Murder-probe-launched-girl-three-drowns-Dalmeny-Hotel-pool-Lancashire.html accessed on 15 April 2020.}

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_{Graham, D. (2016). Inquest into death of Scots girl Jane Bell, 3, who drowned in hotel swimming pool hears there was no on duty lifeguard. (Daily Record, 16 March, 06:00). Available at: https://www.dailyrecord.co.uk/news/scottish-news/inquest-death-scots-girl-jane-7564513 accessed on 15 April 2020.}

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_{HM Senior Coroner for Blackpool & Fylde (2016). Regulation 28: Report to prevent future deaths. Jane Bell. (HM Coroner, 22 March). Available at: https://www.judiciary.uk/wp-content/uploads/2016/06/Bell-2016-0119.pdf accessed on 15 April 2020.}

_{Press Association. (2014). Grandma’s bid to save poor girl, 3. (Mail Online, 15 August, 17:28). Available at: https://www.dailymail.co.uk/wires/pa/article-2725586/Grandmas-bid-save-pool-girl-3.html accessed on 15 April 2020.}

_{QLM (2016). Jane Bell pool death. (QLM, 7 December). Available at: https://qlmconsulting.co.uk/jane-bell-pool-death/ accessed on 15 April 2020.}

_{RLSS UK (2016). Operators urged to make pools safe after toddler drowns in hotel pool. (RLSS UK) Available at: https://www.rlss.org.uk/News/operators-urged-to-make-pools-safe-after-toddler-drowns-in-hotel-pool accessed on 15 April 2020.}

_{Spear, S. (2016). Tragic drowning due to lack of pool supervision. (Environmental Health News, 7 September, 16:15). Available at: http://www.ehn-online.com/news/article.aspx?id=15865 accessed on 15 April 2020.}

_{The Herald (2014). Mother held after girl, 3, dies in hotel swimming pool tragedy. (The Herald, 16 August). Available at: https://www.heraldscotland.com/news/13175215.mother-held-after-girl-3-dies-in-hotel-swimming-pool-tragedy/ accessed on 15 April 2020.}

_{The Newsroom (2016). No lifeguards at hotel where Galashiels toddler drowned. (The Scotsman, 17 March, 17:21). Available at: https://www.scotsman.com/news/uk-news/no-lifeguards-hotel-where-galashiels-toddler-drowned-1480297 accessed on 15 April 2020.}

_{The Newsroom. (2016). Coroner’s plea for action after tot’s pool death. (Lancashire Post, 17 March, 12:32). Available at: https://www.lep.co.uk/news/coroners-plea-action-after-tots-pool-death-787151 accessed on 15 April 2020.}

_{The Newsroom. (2016). Coroner’s plea for action after tot’s pool death. (The Gazette, 17 March, 12:32). Available at: https://www.blackpoolgazette.co.uk/news/coroners-plea-action-after-tots-pool-death-787151 accessed 15 April 2020.}

 

Citation: Jacklin, D. 2020. Case Summary: Jane Bell. Water Incident Research Hub, 21 July.