Case Summary: Maya Kantengule
Mar 25, 2020CASE SUMMARY
Maya Kantengule was 7 years old and lived in Smith’s Walk, Oulton Broad, near Lowestoft, Suffolk (Powell, 2017a). She lived with her father, Livial Kantengule, and her mother, Glenda Kantengule (Powell, 2017a; Keay and Sheppard, 2017a). Maya’s mother and father gave an impact statement on 27 July 2017 at the subsequent inquest, which read (Pringle, 2017):
We are still devastated following the passing of our beloved daughter, Maya Grace Kantengule. The pain is still unbearable and even though it’s been over a year it feels like we relive her passing every day. We hope this inquest will provide answers to what happened on the day, even, though it is hard to admit that no explanation will bring back our daughter. We miss her dearly and she has left a void that is difficult to fill.
Maya’s Headteacher at Dell Primary School, Debbi Flowerdew, said (EADT, 2016a):
The whole community is affected by this terrible news and we are currently supporting the family and other children and families from the school.
The Accident (Sunday 1 May 2016, Waveney Leisure Centre)
Maya was invited to attend her best friend’s birthday party at Waveney Leisure Centre, Staithe Road, Norfolk, on Sunday, 1 May 2016 (HMCO, 2017). WLC includes holiday lodges, camping and boat hire. That party was organised by Mrs Rainer, the mother of Maya’s friend, for her daughter’s birthday party. Her daughter had recently moved from the same school as Maya to another school, and the two were looking forward to seeing each other again. (Powell, 2017a). Mr Kantengule said that Mrs Rainer’s daughter was the only friend they would allow Maya to visit, and Maya had previously been on a boat trip with her. The families knew each other well.
Mrs Rainer chose Waveney River Centre after attending a previous birthday party there. The pool, known as Eddie’s Pool, was 12m x 9m and 1.5m at its deepest (EADTa, 2017; BBC News, 2017a; Cope, 2016). It was an indoor heated pool which had been recently refurbished over the winter and was hired for children’s parties. It was described on the Centre’s website as being suitable for 10 to 20 youngsters.
Mr Kantengule received an invitation for Maya to come to the party. He dropped her off on Sunday, 1 May 2016, at 10:45 at Waverley River Centre in time for the start of the party (Cope, 2016). There were 10 adults and 10 children at the party, including Mrs Rainer’s two daughters. The invitation said children would swim and have lunch, play outside and be ready for collection around 13:30. Mr Kantengule spoke to Mrs Rainer upon arrival and recounted the conversation (Powell, 2017a):
I did not ask if there was a lifeguard and Mrs Rainer did not mention any lifeguard I was aware that Maya could swim but neither myself or my wife had ever seen her swim Jane used to volunteer to help with the swimming lessons, so we assumed Maya would be adequately supervised while in the pool. I got back in my car and drove home as most of the other parents were mums with their daughters. Maya’s mum was at work on the day.
Towards the end of the party, Maya was seen at the bottom of the swimming pool. Maya was recovered from the water prior to the arrival of the emergency services by Mrs Rainer and her daughter. Mrs Rainer began CPR on Maya, which continued until the emergency services arrived.
Mr Kantengule was driving home at the time, and when he got home, he realised he had several missed calls containing a message that Maya had been involved in an accident. Maya’s parents drove to the centre. When they arrived, Maya had already been taken to James Paget University Hospital (HMCO, 2017). They arrived at the hospital and were escorted to Maya’s bedside. Maya was pronounced dead around 16:00 later in the hospital the same day (Powell, 2017a).
Investigation
Immediately following the incident, Mr Knight, the Managing Director and owner of Waverley River Centre, said to the press (Cope, 2016):
We are devastated by this tragedy but want to thank the paramedics, our staff and customers who did everything possible to save the girl’s life, and the police and local authority officers who have been outstandingly professional during these early stages of their investigation. Out of respect for the girl’s family, we will not be re-opening the pool until after this bank holiday weekend and hope that our guests will understand our decision.
A post-mortem was carried out at Great Ormond Street Hospital, London, which gave the medical cause of death as drowning (Powell, 2017b). The park was served an improvement notice by the HSE on 10 August 2016 for failing to have a risk assessment in place for children’s pool parties (Powell, 2017b; Powell, 2017c). The investigation is believed to be ongoing and is considered further below.
Coroner's inquest [2017] (Unreported, Norwich Coroner's Court, 26 July)
An inquest into Maya’s death was held on 26-27 July 2017 at Norwich Coroner’s Court (Gregory, 2017a). Her Majesty’s Coroner, Jacqueline Lake, senior coroner for Norfolk, presided over the two-day inquiry. The purpose of a Coroner’s inquiry is not to establish guilt or innocence but to establish the cause of death. A jury ruled her death was an accident at the conclusion of the two-day inquest (Keay and Sheppard, 2017a). The Inquiry ended on 27 July 2017 (HMCO, 2017).
Maya’s swimming ability
Ms Jaqueline Bell, a teaching assistant at the school, gave a written statement that said (EADT, 2017):
Maya was a non-swimmer. Maya started weekly swimming lessons in reception year and spent around 10 to 15 minutes in the water each time. This was for a few months of the year while the pool was open. She was nervous in the water and would use armbands and a wobble. She could take her feet off the bottom with support but couldn’t do it on her own. The last time Maya would have swum was July 2015.
Mrs Jayne Rainer said (Powell, 2017a):
I spoke to Maya’s father as he dropped her off then helped her put her swimming hat and costume on as she got into a tangle. We laughed about putting her hat on. I walked her along the corridor to the swimming pool, opened the door, called to my daughter that Maya was there. She was my daughter’s best friend. She shrieked with excitement that Maya was here, and they went off to play in the water together.
Supervision of the pool by the hirer
Mr Chris Coker, environmental health officer at South Norfolk Council, told the inquest that the indoor pool at Waveney River Centre could be privately hired. He confirmed the dimensions of the pool and said signs were up stating there were no lifeguards on duty and that people swim at their own risk and should not do so if they are not confident swimmers. The inquest heard evidence from Mr James Knight, the Managing Director and owner of WRC, who said:
Instructions for the pool's use, posted at the entrance and in changing rooms, stated that children under the age of 14 should be supervised by adults. I struggle to believe that anybody would have a group of seven-year-old children in a swimming pool without a single adult supervising them. I do not regard being fully clothed behind the glass as being adequate to supervise seven-year-old children. I believed that there was no risk which could not have been mitigated by normal parental supervision. I never thought anyone would do that. When I did the risk assessment, it did not cross my mind that the normal parental supervision rules would be so comprehensively ignored.
On the matter of the pool CCTV used for supervision, Mr Knight also said reception staff would normally keep an eye on the screens to ensure pool rules were being enforced. Mr Knight said one camera had broken five days earlier, and the replacement was still on his desk at the time of the incident (Powell, 2017c). Mrs Rainer, the hirer of the pool for her daughter’s birthday party, contested Mr Knight’s evidence stating that (Powell, 2017a; Powell, 2017c):
All of the parents that were attending were watching through the windows in the observation areas while the party was taking place, apart from one mother who went outside with her son. I went between the observation area and pool area to take photographs and film the birthday party. No specific discussions were had about supervision. Had we known there was a non-swimmer in the group that would have been completely different. I can’t understand how you can say the children were not being supervised just because we were behind glass.
The emergency response by swimming pool staff
Mrs Rainer said Maya had been in the pool for around half an hour before she went to give the children a ten-minute warning before the end of the pool session (Powell, 2017a). At this point, she saw Maya through the glass observation window at the bottom of the pool. She reported that she ran to the pool area, kicked off her shoes and jumped in fully clothed. Mrs Rainer and her eldest daughter helped lift Maya from the pool. Mrs Rainer performed CPR on Maya at the poolside.
The emergency services were called. A spokesman for the East of England Ambulance Service confirmed attempts were made to resuscitate the girl and said (Cope, 2016):
We received a call to reports of a girl who was found unresponsive in water in Waveney. A rapid response vehicle, two ambulance crews and an air ambulance was dispatched and treated her before conveying to James Paget Hospital via land in a serious condition East Anglian Air Ambulance was called, with doctor and critical-care paramedic landing close to the holiday park.
The police were called by ambulance staff at 12:05 to Waveney River Centre near Beccles following reports a seven-year-old child had been found unconscious in a swimming pool (Sykes, 2016). Maya was taken to the hospital, where she died at approximately 16:00 the same day (EADT, 2016a).
Prevention of Future Deaths Report
The Senior Coroner used her powers under paragraph 7, schedule 5 of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 of the Coroner’s (Investigations) Regulations 2013 to issue what is known as a Prevention of Future Deaths Report (HMCO, 2017). The Report was served on Waveney River Centre on 8 August 2017, 14 months after the accident (HMCO, 2017). It was also copied to the Local Safeguarding Board and South Norfolk Council.
The Coroner’s matters of concern were as follows:
(a) Prior to Maya’s death, an independent contractor had drawn up risk assessments and other health and safety documentation relating to the organisation and use of its facilities by staff and the public. Since 2011, the risk assessments were updated internally and had been deemed ‘suitable and correct’ by South Norfolk Council. Since 2004, no formal health and safety training for directors or staff at Waveney River Centre had been conducted; in particular those responsible for updating, reviewing and checking health and safety documentation.
(b) There was no separate risk assessment for the holding of swimming pool birthday parties. Staff at WRC believed it to be the responsibility of the hirer to provide for the health and safety of guests
(c) Safety procedures had not been followed on the morning of the party. The safety rules had not been discussed with the hirer. Documentation the centre’s only policy required staff to complete with hirers was not signed.
(d) The CCTV used by WRC to monitor the pool area was not working. No checks of the pool party were made by WRC staff to ensure safety rules were followed and understood.
(e) Fourteen months has passed since the incident and no formal health and safety training of directors or staff has taken place. Those representing WRC said they were awaiting the outcome of the inquest before arranging formal health and safety training for Directors. WRC reported that the person reviewing the risk assessments had suffered PTSD as a result of Maya’s death but there was no indication that anyone else had considered undergoing health and safety training such as those ultimately responsible for health and safety. The pool had ceased external pool parties, but the swimming pool is still used by the public for the provision of swimming.
The Coroner gave the Centre 56 days to reply (by 3 October 2017).
Response to the Report by Waveney River Centre
On instruction from Waveney River Centre, solicitors issued a letter dated 6 September 2017 (Kennedys, 2017). The following points were raised in response to the Coroner’s Report in that letter:
South Norfolk Council accepted that for a pool of the size, depth and features that WRC had, there would be no need to continuously supervise the swimming pool stating that swimming pools in hotels and in leisure centres routinely do not have lifeguards. This was confirmed by a leading consultant who conducted a detailed post-incident review.
As regards communication of no lifeguard being provided for the session, WRC says there was a prominent sign on the entrance to the pool making it clear there was no lifeguard. WRC told the hirer in advance of there being no lifeguard. As regards responsibility for supervision, WRC alleges it was the hirer’s duty to supervise the session and that the hirer was deficient in that duty.
(a) The hirer left the pool area on several occasion to go into the changing rooms and that her assertion that there had been no discussion with parents as to the swimming ability of their children does not show that there was not safety brief given.
(b) Hirer stated that she had undertaken supervision with other parents from an observation area overlooking the pool. Hirer accepted she had not given any safety discussion with parents to ask them to take responsibility of the supervision of their children.
(c) Hirer confirmed that at the material time Maya was found, she did not think that there was any adult in the observation area adjacent to the deep end of the pool where Maya was found.
WRC states that South Norfolk Council acknowledged that there was no evidence a separate risk assessment for pool parties would have led to the pool being supervised by WRC staff during pool parties.
(a) WRC would like to add that the Centre no longer holds pool parties and so the risk no longer exists.
(b) WRC disputes the position of the Coroner on whether adequate training was provided for health and safety. The independent safety consultant firm who had worked closely with the company over many years and had provided many hours of mentoring and on-the-job training to the Managing Director of WRC and another member of staff.
(c) WRC disputes the Coroner’s suggestion that the health and safety management arrangements at the Centre were generally deficient stating that the inquiry heard no evidence to support that suggestion.
Post-inquest investigation into Maya Kanengule's death
At the time of publication, there have been no criminal charges or civil claims brought against any party. The Police will decide whether to bring any charge(s) being brought under the Corporate Manslaughter and Corporate Homicide Act 2007 or for Gross Negligence Manslaughter before handing the case over in this case to the HSE because of a conflict of interest with the local Environmental Health Office at South Norfolk Council.
The HSE will then decide whether to bring any charge(s) under the Health and Safety at Work Act 1974 or the associated regulations before concluding that no criminal charge will be brought. The ordinary position would be that any civil claims (psychiatric injury) would be stayed until any criminal proceedings had been concluded. Those with a possible right of action may include the parents and the risk assessor alleged to have suffered PTSD and any witnesses.
The conclusion of the criminal process is taking an average of two to five years at present from the date of the accident. We will update Maya’s Story if there are any further developments at that stage.
References (21)
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.
Baynes, C. and Russell, S. (2017). Young girl drowned at birthday pool party at holiday park with no lifeguard on duty. (Independent, 26 July, 23:51). Available at: https://www.independent.co.uk/news/uk/home-news/young-girl-drown-birthday-pool-party-no-lifeguard-duty-seven-year-old-maya-kantengule-waveney-river-a7861456.html accessed 21 March 2020.
BBC News (2017a). Girl drowned at Norfolk pool party with no lifeguard on duty. (BBC News, 27 July). Available at: https://www.bbc.co.uk/news/uk-england-norfolk-40728517 accessed on 21 March 2020.
BBC News (2017b). Maya Kantengule drowned in an accident, inquest finds. (BBC News, 27 July). Available at: https://www.bbc.com/news/uk-england-norfolk-40740923 accessed 21 March 2020.
Cope, L. (2016). Tragedy as girl, seven, dies at Waveney River Centre swimming pool near Beccles. (Beccles & Bungay Journal, 3 May, 09:42). Available at: https://www.becclesandbungayjournal.co.uk/news/tragedy-as-girl-seven-dies-at-waveney-river-centre-swimming-pool-near-beccles-1-4517518 accessed 21 March 2020.
EADT (2016) School’s tribute to girl who died from drowning at Waveney River Centre. (East Anglian Daily Times, 12 May, 19:16). Available at: https://www.eadt.co.uk/news/school-s-tribute-to-girl-who-died-from-drowning-at-waveney-river-centre-1-4533810 accessed 21 March 2020.
EADT (2017). No lifeguard at Waveney River Centre holiday park pool where Maya Kantengule, seven, drowned, inquest is told (East Anglian Daily Times, 26 July, 13:55). Available at: https://www.eadt.co.uk/news/no-lifeguard-at-waveney-river-centre-holiday-park-pool-where-maya-kantengule-seven-drowned-inquest-is-told-1-5122819 accessed 21 March 2020.
Gregory, J. (2017a). Girl, 7, drowned at Norfolk pool party with no lifeguard on duty. (Guardian, 26 July, 19:07). Available at: https://www.theguardian.com/uk-news/2017/jul/26/girl-7-drowned-at-norfolk-pool-party-with-no-lifeguard-on-duty accessed 21 March 2020.
Hawken, A (2017b). Girl, seven, who was a ‘nervous and wobbly’ swimmer drowned at friend’s birthday pool party while no lifeguard was on duty. (Mail Online, 26 July, 13:50). Available at: https://www.dailymail.co.uk/news/article-4731936/Girl-drowned-friend-s-birthday-pool-party.html accessed 21 March 2020.
HMCO (2017) Regulation 28: Report to Prevent Future Deaths. Her Majesty’s Coroner’s Office. Available at: https://www.judiciary.uk/wp-content/uploads/2017/12/Maya-Kantengule-2017-0317_Redacted.pdf accessed 21 March 2020.
ITV, (2017). No lifeguard on duty at Norfolk pool where schoolgirl drowned. (ITV News, 26 July, 13:03). Available at: https://www.itv.com/news/anglia/2017-07-26/no-lifeguard-on-duty-at-norfolk-pool-where-schoolgirl-drowned/ accessed 21 March 2020.
Keay, L and Sheppard, J (2017a) Pool boss accuses parents of not keeping a proper watch on birthday party where seven-year-old girl drowned. (Mail Online, 28 July, 12:18). Available at: https://www.dailymail.co.uk/news/article-4735574/Parents-girl-drowned-pool-party-speak-loss.html accessed 21 March 2020.
Mann, T. (2016). Girl, 7, dies after being pulled out of swimming pool unconscious. (Metro, 1 May, 19:30). Available at: https://metro.co.uk/2016/05/01/girl-7-dies-after-being-pulled-out-of-swimming-pool-unconscious-5853399/ accessed 21 March 2020.
McGloughlin, R. (2016) More very sad news from swimming pool with no lifeguard. (Poolview, 2 May). Available at: http://www.poolview.co.uk/news/more-very-very-sad-news-from-swimming-pool-with-no-lifeguard accessed 21 March 2020.
Powell, L (2017a). No lifeguard at pool at Waveney River Centre holiday park where Maya Kantengule drowned at friend’s birthday party, inquest told (Eastern Daily Press, 27 July, 11:08) available at: https://www.edp24.co.uk/news/no-lifeguard-at-pool-at-waveney-river-centre-holiday-park-where-maya-kantengule-drowned-at-friend-s-birthday-party-inquest-told-1-5122790 accessed 21 March 2020.
Powell, L (2017b). Coroner’s concern that staff are yet to undergo health and safety training at Waveney River Centre holiday park where Maya Kantengule drowned (Eastern Daily Press, 27 July, 19:23). Available at: https://www.edp24.co.uk/news/coroner-s-concern-that-staff-are-yet-to-undergo-health-and-safety-training-at-waveney-river-centre-holiday-park-where-maya-kantengule-drowned-1-5125185 accessed 21 March 2020.
Powell, L (2017c). Holiday park managing director tells Maya Kantengule inquest that adult supervision of pool was not ‘adequate’. (Eastern Daily Press, 27 July, 17:35). Available at: https://www.edp24.co.uk/news/holiday-park-managing-director-tells-maya-kantengule-inquest-that-adult-supervision-of-pool-was-not-adequate-1-5124624 accessed 21 March 2020.
Powell, L (2017d). Inquest into death of seven-year-old girl at Burgh St Peter swimming pool to take two days (Eastern Daily Press, 03 July, 17:40). Available at: https://www.edp24.co.uk/news/inquest-into-death-of-seven-year-old-girl-at-burgh-st-peter-swimming-pool-to-take-two-days-1-5089730 accessed 21 March 2020.
Powell, L (2017e) Coroner’s concern that staff are yet to undergo health and safety training at Waveney River Centre holiday park where Maya Kantengule drowned. (The Lowestoft Journal, 27 July, 19:23). Available at: https://www.lowestoftjournal.co.uk/news/coroner-s-concern-that-staff-are-yet-to-undergo-health-and-safety-training-at-waveney-river-centre-holiday-park-where-maya-kantengule-drowned-1-5125185 accessed 21 March 2020.
Pringle, E (2017) Family of Maya Kantengule, 7, pay tribute following her death at Waveney River Centre holiday park. (Eastern Daily Press, 27 July, 15:02). Available at: https://www.edp24.co.uk/news/family-of-maya-kantengule-7-pay-tribute-following-her-death-at-waveney-river-centre-holiday-park-1-5124139 accessed on 21 March 2020.
Russell, S. (2017). Girl, 7, drowned at best friend’s swimming pool birthday party with no lifeguard on duty. (Mirror, 26 July, 14:08). Available at: https://www.mirror.co.uk/news/uk-news/girl-7-drowned-best-friends-10874493 accessed 21 March 2020.
Sykes, S. (2016) Girl, aged seven, dies in swimming pool tragedy at holiday park. (Express, 1 May, 19:26). Available at: https://www.express.co.uk/news/uk/666176/Girl-seven-dies-swimming-pool-Waveney-River-Centre-Great-Yarmouth-Burgh-St-Peter-Norfolk accessed on 21 March 2020.
Citation: Jacklin, D. 2020. Case Summary: Maya Kantengule. Water Incident Research Hub, 21 March.
