Case Summary: Madhav CherukuriMar 25, 2020
Madhav Cherukuri was a 25-year-old Staffordshire University international student from India. He was staying with a friend during the University summer break before he returned to finish his studies in September.
On Wednesday, 30 August 2006, Mr Cherukuri borrowed his university friends’ health club pass to enter the Spindles Health Club at the Adelphi Hotel, Liverpool. At around 09:30, he accessed the swimming pool unchallenged by the reception team. The pool had risk assessed that it did not need to provide a lifeguard for the swimming pool. Madhav entered the Health Club and the swimming pool.
Mr Cherukuri was seen by other swimmers engaging in breath-holding exercises and extended swimming underwater. A fellow swimmer, Ms Elizabeth Hutton, who did not know Mr Cherukuri became so concerned by his breath-holding exercises that she exited the poolside to seek assistance from hotel staff. She exited through the changing rooms and into reception to alert them to her concerns about Mr Cherukuri’s behaviour (Liverpool Echo, 2009).
When Ms Hutton returned with member of staff, Mr Michael Johnson who was a trained lifeguard, Mr Cherukuri was lying motionless on the bottom of the pool. The two pulled Mr Cherukuri from the water and began CPR, supported by two off-duty nurses (Liverpool Echo, 2009). The emergency services were called.
Mr Cherukuri was later pronounced dead upon arrival at the hospital as a result of his injuries.
Inquest into the death of Madhav Cherukuri (2006) (Unreported)
Madhav’s death was placed under the jurisdiction of the Coroner for reason that the cause of death was unknown. There was a requirement to hold a jury inquest. One impact of jury inquests is that there is no requirement to give reasons which are in contrast to Coroner’ led inquests where the Coroner can and most often does give reasons.
The inquest was held in September 2006. The Coroner is required to decide who the deceased was and where, when and how they died. The jury had the role of deciding the cause of death. This is assessed on the balance of probabilities.
The hotel’s then manager, Eileen Downey, the Adelphi Hotel manager at the time of the incident said that the Hotel was not obliged to have a lifeguard on duty but provided one on a voluntary basis (Liverpool Echo, 2009).
The jury heard evidence that there were several occasions leading up to the event where no lifeguards were present on hotel premises for several hours at a time. The inquest also heard evidence that a pool attendant had first prodded Mr Cherukuri with a net before proceeding to initiate a rescue to recover him to the poolside.
A narrative verdict was reached by the jury confirming Mr Cherukuri had drowned (Liverpool Echo, 2009).
The criminal investigation by Liverpool City Council
An investigation was launched firstly by the police for manslaughter but was satisfied that there was no case for gross negligence manslaughter and handed the case to the local Environmental Health Office at Liverpool City Council who investigated the accident (Stewart, 2010).
The EHOs found evidence that staff had not been sufficiently trained to handle emergencies and had not undertaken in-service training (QLM, 2010). The EHO also found exposed electrical conductors in a service tunnel adjacent to the swimming pool which was unrelated to Mr Cherukuri’s accident. The EHO issued the Adelphi Hotel with a Prohibition Notice, based on the exposed live conductors, in September 2006 which required the swimming pool’s closure until an adequate maintenance programme was operational (SHP, 2010). Expert evidence from electrical inspector Stephen Frost supported the concerns with electrical safety at trial (Stewart, 2010).
The EHO also found that the most recent risk assessment was 2003, some three years prior to the accident. The risk assessment identified the risk of drowning but did not mention the need for constant poolside supervision (Stewart, 2010).
The EHO’s investigation into Mr Cherukuri’s accident concluded, that there was sufficient evidence for two charges. The Britannia Adelphi Hotel was charged with one count of a breach of s.3(1) of the Health and Safety at Work etc. Act 1974 (HSWA 1974) for a failure to protect the health and safety of a person not in their employment. They were also charged with one count of a breach of Regulation 3(1) Management of Health and Safety at Work Regulations 1999.
R v Britannia Adelphi Hotel Ltd  (Unreported, 6 August, Liverpool Crown Court)
A criminal investigation against Britannia Adelphi Hotel Ltd was brought and the Hotel was charged with one count of a breach of s.3(1) of HSWA 1974. The case was heard in Liverpool Magistrates Court on 6 August 2009. The case was sent to Liverpool Crown Court for trial.
At the pre-trial preparation hearing (PTPH) at Liverpool Crown Court on 15th December 2009, Britannia Adelphi Hotel entered a not-guilty plea to one count of breach s.3(1) of the HSWA 1974. A second charge under the Electricity at Work Regulations 1989 is spoken about in consideration, but it is the author's view that either this is a misunderstanding by the reporting journalist of the s.3(1) charge or it was dropped at an early stage. In any event, it had nothing to do with the material circumstances leading to Mr Cherukuri's death. The hearing was adjourned until February 2010, with the trial scheduled for May 2010.
At Liverpool Crown Court on 5 August 2010, immediately prior to the start of the trial, Britannia Hotel changed its plea to guilty to a breach of s.3(1) HSWA 1974. HHJ Morrow QC adjourned the case for a Newton hearing to decide factual disagreements over what safety measures should have been in place (Liverpool Echo, 2010b).
At the Newton hearing on 5 August 2010, HHJ Morrow QC heard evidence of industry standards in place for the requirement of constant poolside supervision. The Prosecutor, Mr Lawrence (now QC) also pointed out a 2003 risk assessment carried out by the hotel that identified a risk of drowning but did not mention the need for constant poolside supervision (Stewart, 2013). The Prosecution did not push for HHJ to make a finding as to whether the swimming pool required continuous lifeguard supervision in line with industry guidance in place at the time of the accident in 2006. Instead, Mr Lawrence said that the Prosecution’s position was that the Hotel failed to carry out a suitable and sufficient risk assessment of whether continuous lifeguard supervision was needed. As such, HHJ was not required to find as a fact whether the pool required continuous lifeguard supervision or not.
The Court was also told that Mr Frost, an electrical inspector acting in the capacity of an expert witness, had conducted a thorough investigation and found a number of problems with electrical safety. He cited exposed live conductors, a junction box in the sauna sealed with tape, and electrical sockets corroded with a substance including chlorine.
Mr Mark Turner QC, defending, offered his condolences to Mr Cherukuri’s family who remained in India throughout the proceedings. The Hotel admitted that they could have done more to inform lifeguards about how frequently they should check the pool. Mr Turner QC also said, on behalf of the Hotel, that had the Hotel lived up to the required standard, which they admit they fell short of, there is no guarantee this death would not have happened anyway (Stewart, 2013). The Hotel said in mitigation that it had no previous convictions and had fully cooperated with the investigation and ensured that all lifeguards had now received in-service training and reduced the depth of the swimming pool.
HHJ Morrow QC sentenced the Hotel to pay a £65,000 fine plus the reimbursement of £70,000 of the Prosecution's costs of bringing the case. HHJ remarked (Stewart, 2010):
The value of the fine is not to be seen as a measure of Mr Cherukuri's life which was tragically cut short. The sentence is not based on the lack of continuous lifeguard supervision, but on the inadequate risk assessment of the need to provide supervision. On 14 occasions in the 9 months leading up to the accident, there had been no lifeguard at the premises and no ongoing training for lifeguards. I acknowledge the Hotel's previously good safety record and that it has been visited by hundreds of thousands of swimmers safely previously.
HHJ said that Mr Cherukuri’s concerning behaviour may have been part of a fitness regime that caused him to blackout and then drown (Stewart, 2013). Councillor Tim Moore and Cabinet Member of Liverpool City Council said following the judgment (SHP, 2010):
This unfortunate incident has highlighted the matters that leisure-pool operators need to consider when devising operational procedures. Lifeguards and other employees need to be properly trained to recognise and deal with emergency situations.
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.
BBC (2006). Man drowns in hotel swimming pool. (BBC News, 31 August, 12:56). Available at: http://news.bbc.co.uk/1/hi/england/merseyside/5302264.stm accessed 22 March 2020.
Liverpool Echo (2009). Liverpool’s Adelphi Hotel denies breaking safety laws prior to swimmer drowning. (Liverpool Echo, 16 Dec, 17:31). Available at: https://www.liverpoolecho.co.uk/news/liverpool-news/liverpools-adelphi-hotel-denies-breaking-3436771 accessed 22 March 2020.
Liverpool Echo (2010a). Adelphi hotel admits breaching safety laws over student drowning. (Liverpool Echo, 13 May, 07:30). Available at: https://www.liverpoolecho.co.uk/news/liverpool-news/adelphi-hotel-admits-breaching-safety-3423121 accessed 22 March 2020.
Liverpool Echo (2010b). Adelphi hotel sentencing adjourned until August. (Liverpool Echo, 14 May, 00:00). Available at: https://www.liverpoolecho.co.uk/news/liverpool-news/adelphi-hotel-sentencing-adjourned-until-3423199 accessed 22 March 2020.
QLM (2010) Health and Safety Newsletter. Issue 38. (QLM, October). Available at: http://qlmconsulting.co.uk/wp-content/uploads/2017/05/Oct-2010-Newsletter.pdf accessed 22 March 2020.
SHP (2010). Health club lifeguards were not trained to deal with emergency. (SHP Online). Available at: https://www.shponline.co.uk/in-court/health-club-lifeguards-were-not-trained-to-deal-with-emergency/ accessed 16 March 2020.
Stewart, G (2010). Liverpool’s Adelphi Hotel to pay £135,000 in costs and fines after swimming pool death. (Liverpool Echo, 6 Aug, 07:25). Available at: https://www.liverpoolecho.co.uk/news/liverpool-news/liverpools-adelphi-hotel-pay-135000-3398240 accessed 22 March 2020.
Citation: Jacklin, D. 2020. Case Summary. Madhav Cherukuri. Water Incident Research Hub, 21 March.