Case Summary: Keenan Walsh
Oct 30, 2020CASE SUMMARY
Keenan Walsh was four years old when on Friday, 23 August 2013, he drowned in the 2.7-metre-deep end of the indoor swimming pool at Bicclescombe Grange at Ilfracombe in North Devon. Keenan was on holiday, his dad and step-mum having booked the Grange, a private hire four-star holiday home, along with other friends and their children. Keenan was from Uxbridge in West London and was in a large party that included twelve other children who were all staying with their families at Bicclescombe Grange (Di-Salvo, 2016).
The family arrived late on the afternoon of 23 August, and at some time between 17:45 and 18:17, Keenan got into difficulty in the deep end of the pool. 12 other children were playing in the pool at the time of the incident, but neither adults nor other children spotted Keenan. His body is thought to have been obscured by floats and toy inflatables.
Keenan’s father, James Walsh, told the later Coroner’s inquest:
Keenan was a non-swimmer, and I was playing with Keenan in the shallow end until he climbed out around 17:45. I dried him and watched him enter the changing room. This was the last time I saw Keenan alive. I stayed in the pool with the other children when one of the children shouted that Keenan was at the bottom.
At around 18:17, paramedics were called to the scene shortly after Keenan was rescued and recovered to the poolside. He was not breathing, and CPR was commenced. A first responder arrived to support the resuscitation efforts. When paramedics arrived at the Grange, Keenan was still not breathing. An Ambulance spokesperson would later confirm that Keenan had regained cardiac output before he was transferred to North Devon District Hospital (Stretch, 2013).
Keenan’s condition remained critical, and he was subsequently airlifted to Bristol’s Specialist Children's Hospital. He had suffered extensive brain damage from the cardiac arrest induced by drowning. On 28 August, five days after the accident and still on life support, doctors took the difficult decision to switch off Keenan’s life support resulting in Keenan being pronounced dead the same day.
Investigation
Bicclescombe Grange was owned and operated as a holiday let (country home for hire by large parties) by Mr and Mrs Swinton. After the initial Devon and Cornwall Police visit and taking of statements, the police handed the case to the HSE for further investigation. Due to confusion between the HSE and the local authority about who held enforcement responsibility for residential pools supplying commercial activities, such as holiday lets, the HSE made the decision to take control of the investigation.
The owners of the hotel, who were away at the time of the accident, said:
All our thoughts, my wife and I, are with them and their family. We were completely shocked when we heard; it was a terrible tragedy. My understanding is it has been a tragic accident. He said they had met with the police and officials at the holiday accommodation yesterday (Tuesday) and no concerns had been raised about the facilities on site.
We are very distressed at what has happened, and we are still reeling with shock. This is a tragedy, and my understanding is that this is a tragic accident. All our thoughts are with the family at this very difficult time.
The HSE have attended, and we have cooperated fully with their investigation. We have got all the signage up we should have. It is a very secure pool with double-locked doors. The HSE has examined the pool and found nothing untoward. We still do not understand how this has happened.
A police spokesman said (Gussin, 2013):
This was a very tragic incident, and the circumstances are not known at this time. A full investigation is underway, with the police public protection unit liaising with partner organisations.
Jeremy Mann, Head of Environmental Health and Housing Services at North Devon Council, said:
We have been informed of the tragic incident, which is currently being investigated by the police. We have visited the site in support of the ongoing police investigation but are unable to make any further comment at this time.
It was later decided jointly by enforcement authorities that, due to a lack of guidance and industry consensus around the standard of care expected in the supervision of holiday let pools, no prosecution would be brought against the Grange or any other person.
Coroner’s Inquest
Dr Elizabeth Earland, Senior Coroner for Exeter and Greater Devon, commenced the inquest into Keenan’s death on 16 September 2013, within a few weeks of the accident. I have added a note about Dr Earland below because, during the same period as Keenan’s death, she was driving positive change in the Coronial system following the eight-year wait for the inquest into Adrian Pullman’s death.
Dr Earland issued a report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013; known by its shorthand as a Regulation 28 Prevention of Future Deaths report. The report was issued on the 27th of May 2016 and was addressed to Devon County Council and North Devon District Council. Below is a summary of the key points of that report:
(a) On 16 September 2013, I commenced an investigation into the death of Keenan John Walsh, aged 4 years. The investigation concluded at the end of the inquest on Wednesday 25 May 2016. The conclusion of the inquest was a narrative conclusion as follows:
(b) Keenan, a non-swimmer, died as a result of a tragic drowning accident in the 9-foot-deep end of a heated swimming pool at Bicclescombe Grace, Kingsley Avenue, Ilfracombe, whilst attending a large family party.
(c) Sometime between 17:45 hours and 18:17 hours on 23 August 2013, Keenan submerged in the deep end of the pool whilst inadequately supervised in the company of a permutation of 12 children jumping in and out and two adults, neither of whom were available to rescue him. The slope of the deep end was a factor. Vision was obscured by large numbers of inflatables.
(d) Immediate attempts at resuscitation and subsequent transfer to North Devon District Hospital, then Paediatric Intensive Care Unit at Bristol Children’s Hospital, failed to avert his subsequent death from complications of near-drowning.
(e) During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you.
(f) The matters of concern are as follows:
- At the time of the incident private holiday lets with swimming pools were not regulated by the Health and Safety Department of Local Authority Environmental Health, despite tourism being a significant part of the local economy.
- Although there was a limited amount of signage, the profile of the swimming pool fell outside accepted standards and presented a significant hazard to non-swimmers approaching a sharp slope to the deep end.
- The ratio of competent adults to children was one adult to anything up to twelve children at the time of the incident. The ratio was against the advice of the proprietors but unenforceable. Responsibility lay with adult family members.
(g) In my opinion, action should be taken to prevent future deaths and I believe your organisation have the power to take such action. I refer you to the advice received from the EHO in her report:
Pool Profile
(h) The gradient of the swimming pool in water depths of 1.5m and 1.35m had been calculated as approximately 1 in 3.7. This means that the pool does not comply with either the new European Standard BS EN 15288-2:2008 or the standard outlined in HSG179 (v3) these being 1 in 10 and 1 in 15 respectively. The Officers have strongly recommended that the owners consider re-profiling the floor of the pool to a gradient which meets the requirements of those standards.
(i) In the meantime, Officers have recommended that:
- A diagram showing the pool depth and profile should be displayed on poolside.
- The steps of the pool should be clearly marked at areas of steep gradient with signs erected warning of the sudden change in depth.
- To consider the possibility of introducing a physical barrier between the changes of water depth. This could include the provision of floating buoys, for example.
- Consider clearly marking the areas of steep gradient with coloured pool tank markings.
Signage
- Clear, water depth signs should be provided which are clearly visible to bathers when they are both on the pool surrounds and in the water.
- Signs indicating general ‘do’s’ and ‘don’ts’ should be placed prominently on poolside. Warning signs such as ‘No Diving’, etc., should be displayed in a pictorial format to comply with the Health & Safety (Safety Signs and Signals) Regulations 1996.
Access to the pool
- A high handle, ‘out of reach’ of younger children should be provided on the main entrance door to the pool hall.
- Access to the pool hall is located close to deep water. Bathers may enter the water at the first entry point without checking that the water depth is appropriate – a particular problem for children and inexperienced swimmers. A physical barrier, such as a guard rail could be provided. Under the circumstances, we would agree that a guard-rail and warning signs would be appropriate.
Further to this, she stated in evidence that it had recently been decided by the Legal Department that such holiday lets would fall to be included with the provisions of Section 3 Health and Safety at Work Act 1974 (the proprietors being self-employed). If this is so, I invite you to clarify this point with all involved in the tourist industry in the country and take such action as is felt necessary.
The Coroner provided the statutory 56 days for Devon County Council and North Devon District Council to respond to this report.
Responses to the Coroner’s Regulation 28 report
Devon County Council responded to the Coroner’s Notice on 22 July 2016, following the notice, and two further letters from the Coroner, 20 June and 4 July 2016, respectively.
We note the content of North Devon Council’s response and agree with them that the responsibility for enforcing health and safety in holiday lets sits with the District Council’s across Devon. In light of this, Devon County Council has no power to make changes to improve practice as that power is in the hands of the District Councils.
Devon County Council no longer undertakes tourism operational activities as these are in the process of being transferred to the “Visit Devon Community Interest Company” however, Devon County Council shall raise the issue with this organisation so that it may raise awareness of the issue across Devon.
North Devon District Council responded to the Coroner’s Notice on 28 June 2016.
NDC is an authority responsible for enforcing health and safety by virtue of the Secretary of State’s power under section 18 HSWA 1974 to delegate responsibility to NDC which took place via The Health and Safety (Enforcing Authority Regulations 1998. Schedule 1, paragraph 5 of those Regulations provides that enforcement for the site is that of the District Council in cases where the provision of permanent or temporary residential accommodation including the provision of a site for caravans or campers.
The efforts of Keenan’s family to raise awareness and mark Keenan’s memory
At the time of the accident, Keenan’s mum, Heide, was at home in London, having separated from Keenan’s father. Heide would receive the news that no parent ever wants to hear, saying shortly after the accident (Raven, 2014):
I was not with them when Keenan died. Nothing has been elaborated on, but there were so many people on that holiday, it should not have happened. I feel like I am in limbo and cannot grieve for the death of my youngest son until I know what happened to him.
Keenan was the youngest of his four brothers and sisters: Mikey, 14; Brandon, 12; Shannon, 9; and Tommy, 7. Keenan was part of a close travelling family living in Harefield and attending Harefield Infant school. Hundreds of relatives and members of the travelling community turned out to Keenan’s funeral to watch white horses with red plumes pulling a glass carriage laden with flowers and his tiny coffin. Heide said (Raven, 2014):
In the midst of all this and with so many unanswered questions, I have decided to make something positive from Keenan’s death.
People say I am brave but I am not. That wall will soon come crashing down. The support I have had from the community and the schools so far has been great. My children are adjusting to what has happened. Tommy is autistic, and whilst he is a very bright boy, he is finding it difficult to understand. The other children are coping well, considering what they have been through.
I want to raise as much as possible. I can’t put a figure on it. After these events, I want to carry on doing little fund-raising events throughout the year. I have always wanted to do something for the hospital after Keenan spent two weeks at Great Ormand Street Hospital as an eight-month-old baby with meningitis. He was a little fighter.
My friend Lisa Lewis, the mother of Keenan’s best friend, and I are organising two charity events to raise money for the Keenan Walsh Brighter Future Fund, with profits going to Great Ormond Street Hospital (GOSH).
We are hosting a ladies night at Harefield Football Club in Northwood Way and on the 24th August 2014, the anniversary of Keenan’s death, we are holding a fun day at British Legion in High Street. My son Brandon is growing a ponytail which he will shave off during the August event and has already collected more than £400 sponsorship. I am also collecting toys to donate to GOSH.
Note on the Coroner
Dr Elizabeth Earland also presided over the inquest of Adrian Pullman from 2003-2012 led to reform in coronial practice, namely in the form of the proposed Coroners Charter (described in my article on Adrian’s story) which led to higher standards of coronial practice for families. She first qualified as a doctor in 1972, a GP in 1982, and an anaesthetist around the same time, working in the UK and Abu Dhabi before a career change into hotel ownership in 1978 as she brought up her two sons. Dr Earland moved to Exeter in 1982 and continued working as a doctor. In 1992, she left the NHS and completed the GDL in 1993 and then the LPC in 1994. She qualified as a solicitor specialising in clinical negligence in 1996.
In 1998, Dr Earland became HM Assistant Deputy Coroner, then HM Deputy Coroner in 1999, and, leaving private practice behind, became HM Coroner for the County of Devon in 2003, where she served until around 2019. She received an Honorary Doctor of Laws (LLD) in 2013 from the University of Exeter, recognising her work and contribution to the reform of coronial practice over many years. A contribution to drowning prevention which continues today, following the reforms including reduced waiting times for inquests and the publication of Regulation 28 reports on which many of these stories rely. Regulation 28 reports are one of only a handful of public records covering the facts of cases resolved in lower courts where no judgment is published, cases settled out of court, or not pursued by enforcement authorities.
References (9)
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.
DiSalvo, M. (2016). Hols boy, 4, drowned in indoor pool. (Daily Mirror, 24th May). Available at: https://www.pressreader.com/uk/daily-mirror/20160524/281638189443113 accessed 30th October 2020.
Gussin, T. (2013). Boy, 4, dies in pool tragedy. (North Devon Gazette, 28th August, 13:49). Available at: https://www.northdevongazette.co.uk/news/boy-4-dies-in-pool-tragedy-1-2355723 accessed 30th October 2020.
Hayhurst, C. (2013). Boy (4) dies in holiday tragedy. (29th August, 10:53). Available at: https://www.belfasttelegraph.co.uk/news/uk/boy-4-dies-in-holiday-tragedy-29535372.html accessed 30th October 2020.
HuffPost. (2013). Boy, 4, dies after holiday swimming pool ordeal. (28th August, 12:45). Available at: https://www.huffingtonpost.co.uk/2013/08/28/boy-4-dies-after-holiday-swimming-pool-ordeal_n_3830231.html accessed 30th October 2020.
ITV News (2013). 4-year-old boy drowns at hotel. (28th August, 00:00). Available at: https://www.itv.com/news/westcountry/story/2013-08-28/4-year-old-boy-drowns-at-hotel/ accessed 30th October 2020.
Matthews, A. (2016). Boy, four, who drowned on family holiday at a luxury resort wandered away from his father after they’d been playing in the pool. (Mail Online, 23rd May, 17:18). Available at: https://www.dailymail.co.uk/news/article-3605145/Boy-four-holiday-father-stepmother-drowned-pool-new-family-s-luxury-resort.html accessed 30th October 2020.
Raven, H. (2014). Mother of 4-year-old who died in a swimming pool tells of her heartbreak. (My London, 19th December, 13:38). Available at: https://www.mylondon.news/news/local-news/mother-4-year-old-who-died-swimming-7196191 accessed 30th October 2020.
Sanderson, D. (2013). Parents urged to be on the alert after two boys drown within days. (The Times, 29th August, 01:01). Available at: https://www.thetimes.co.uk/article/parents-urged-to-be-on-the-alert-after-two-boys-drown-within-days-08gq0998tjr accessed 30th October 2020.
Stretch, E. (2013). Boy’s life support switched off four days after being pulled unconscious from swimming pool. (28th August, 18:39). Available at: https://www.mirror.co.uk/news/uk-news/bicclescombe-grange-tragedy-boys-life-2234217 accessed 30th October 2020.
Citation: Jacklin, D. 2020. Case Summary: Keenan Walsh. Water Incident Research Hub, 30 October.
