Case Summary: Michelle Gellard
Jan 31, 2021CASE SUMMARY
Michelle Gellard, who has seven-years-old attended Docklands Dragons Judo Club and attended a judo competition with her family and friends at the Blackwater Leisure Centre in Maldon, Essex, on Saturday 14 June 2008. The leisure centre was operated by Leisure Connection on behalf of Maldon District Council (Burton, 2012). Leisure Connection runs more than 70 leisure and arts facilities across the UK.
Michelle won a silver model at the judo competition and at around 13:30, Michelle and her friends went to use the swimming pool as a reward following the competition (Brooke, 2012). The pool was running a fun-for-all general swim session aimed at families. The Maldon leisure pool included a flume, whirlpools, a waterfall, and a jungle river.
Michelle went to the pool with five other children and Sylvie Zoetman, a mum of one of the youngsters. Two lifeguards were on the poolside on the day (Brooke, 2013). A third lifeguard which was typically allocated to cover the deep lagoon pool was unattended due to staffing shortages that day at the site.
Michelle and the rest of the family got into the pool at around 13:30. No one in the pool saw Michelle get into difficulty. At around 14:00, Michelle was spotted at the bottom of the 1.8-metre-deep lagoon pool and recovered from the water by a lifeguard and fellow swimmer (Brooke, 2012).
Three teenage St. John Ambulance cadets, Carrie Mynard, Claire Cook and Chelsie Knight (who were 16, 16, and 17-years-old respectively) were providing first aid cover for the judo competition and heard the pool alarm activated when Michelle was found. The teenagers described hearing over the tannoy an announcement to attend poolside and attended to offer their help. Claire Cook said (Maldon Standard, Oct 2008):
I got the public to move back and I was sitting with Michelle’s sisters, going through with them what they saw. It was a bit of an adrenalin rush but I did the job I was there to do.
Chelsie, who wants to be a paramedic, is qualified in giving oxygen and pain-relieving gases. She set up the equipment so the attending paramedics could administer it. She said (Maldon Standard, Oct 2008):
I also took over from the lifeguard and did some CPR. I can’t put it into words. It felt like we were there for hours, but it was only minutes. It all happened very quickly and was over in a flash.
Carrie said (Maldon Standard, Oct 2008):
I was more involved with Michelle’s mother at the time. I was trying to calm her down and gave her information about what was going on.
There was some confusion about the 999-call made by centre staff and received by paramedics. It had led paramedics to believe that Michelle had been choking but was conscious and breathing when in fact resuscitation had continued until the paramedics had arrived. Michelle was flown to Colchester General Hospital where she was pronounced dead the same day (BBC News, July 2013).
Funeral
Michelle’s funeral took place at the Quaystone Church at Millwall’s Docklands. Her pink coffin was later taken to the City of London Cemetery at Manor Park for cremation (Brooke, 2013). Michelle was described as a loving, confident and helpful little girl by her family. Her parents Mark Gellard and Sian Lakey said (Gazette News, June 2008; Brooke, 2013; Brooke, 2012):
Michelle was a cheeky little madam with attitude who could make anyone laugh, but was also a loving, helpful and confident little girl.
We have been overwhelmed by the messages of sympathy from individuals and community groups alike, and thanked teachers from the Harbinger School, where Michelle was a pupil. Michelle loved her Judo and was always dreaming up ideas for the club.
Special thanks were given to Dr Angela Tillett and the nurses at Colchester General Hospital for the sensitivity and tenderness they showed towards the family (Gazette News, June 2008). Head-teacher Mandy Kellegher said that Michelle had an extraordinary gift for caring for others (Brooke, 2013). Assemblies had been held at Michelle’s school, Harbinger Primary and classmates offered counselling. The pupils had lit candles in remembrance of Michelle (Brooke, 2012).
Fred Turner who helped lead Docklands Dragons Judo Club where Michelle had attended Judo and represented the club in the competition earlier that day described Michelle as a live wire who was always on the go (Brooke, 2013). A neighbour who lived near Michelle’s family home said (Metro, June 2008):
Michelle was always outside playing with her father and siblings. Her mother and father were together which is quite unusual for families in this area. Michelle was a smiley child. It was the happiest of homes. It is so heartbreaking to hear this news. I have not seen her parents yet, but I think residents around here will be doing all they can to help them.
The three St. John’s Ambulance Service Cadets, Carrie Mynard, Claire Cook and Chelsie Knight (who were 16, 16, and 17-years-old respectively) who had assisted in Michelle’s resuscitation are all to be recognised for their efforts by receipt of a Young Achievers’ Award presented by HRH Princess Anne, The Princess Royal, in a ceremony on Wednesday 8th October 2012 at Buckingham Palace.
Coroner’s inquest (13 May 2011, Chelmsford Coroners Court, Essex Record Office)
The Coroner’s inquest into Michelle’s death was opened and adjourned shortly following her death to allow the investigation into the circumstances surrounding her death to proceed. The jury inquest was then scheduled to take place over five days 9th-13th May 2011 at Chelmsford Coroner’s Court sitting at the Essex Record Office (Burton, 2012; BBC, May 2011). The inquest heard from pathologist Dr David Rouse who said (London Evening Standard, May 2011; Keeley, 2011; Express, May 2011):
My opinion is that Michelle drowned. She had suffered a bruise the size of a 20 pence piece on the back of her head which she may have suffered during the judo competition or later on whilst in the pool. She may have slipped, fallen into the water, and knocked herself unconscious.
It is possible that Michelle could have suffered from an undetected heart problem which induced a cardiac arrest whilst in the pool, which would trigger the drowning process. She could also have choked on her own vomit whilst swimming and choked after exercising too much. He said it was impossible to say whether she could have been revived as he did not know exactly what led to the drowning. Children do drown in swimming pools, but the post-mortem cannot help further than that.
My opinion is that Michelle died from drowning, but I cannot conclude what caused her to drown.
The jury also heard evidence from neuropathologist Dr Al-Sarraj who gave evidence at the inquest (Keeley, 2011). The jury returned a verdict of accidental death by immersion (BBC News, July 2013; BBC News, August 2012). Peter Todd, Partner at Hodge Jones and Allen Solicitors LLP representing Michelle’s parents, said (Cornell, 2008; Maldon Standard, May 2011; Sam-Daliri, 2011; Express, May 2011):
Michelle’s parents want a full and independent investigation into this incident carried out. We have asked the HSE to review their decision only to investigate the involvement of the council. We would like them also to investigate the involvement of Leisure Connection Limited.
Allegations have also been made regarding the state of facilities. We question how Maldon District Council can conduct a proper investigation if it may also have contributed to what happened here.
This case potentially has significant implications for all those involved in lifeguarding or managing a swimming pool, and for parents of children using a pool. It is important lessons are learned to ensure this particularly distressing tragedy never happens again.
There was nobody in that position before the rotation and there wasn’t going to be anyone there after the rotation. If you are down one person, there is too much water to supervise. There are parts of the pool you cannot effectively supervise. The emergency call made to paramedics is also a contributing factor in delaying their arrival at the centre. Michelle's parents believe this call was why paramedics did not arrive as quickly as they could have done.
It is a fair verdict and Michelle’s parents took a certain amount of reassurance from it. The family is still concerned over the number of lifeguards on duty at the pool that day. Michelle was found by a lifeguard and another swimmer.
The family are investigating whether to bring a civil prosecution against Leisure Connection for their role in Michelle’s death.
Michelle’s parents had moved from Cubitt Town to Kent with their other three children soon after the tragedy. The family had returned to the Isle of Dogs in 2010. Michelle's mother, Sian Lakey, and her father, Mark Gellard, said after the verdict (London Evening Standard, May 2011):
We hope as a result of this inquiry that lessons will have been learned and that such an unspeakable tragedy will never happen again.
After the hearing, Health and Safety Executive inspector Antonina Drury said (BBC News, July 2013):
This tragic and untimely death should never have happened. Members of the public visiting leisure centre swimming pools have an entitlement to expect that the operator paid to run them will deploy and train its staff so as to provide sufficient numbers of lifeguards in the right places so as to operate the pool safely.
Leisure Connection, which runs the centre, said in a statement after the verdict at Essex Record Office, Chelmsford (Sam-Daliri, 2011; BBC News, May 2011):
Our sympathies remain with Michelle’s family in their tragic loss. Leisure Connection remains fully committed to ensuring that its policy and procedures comply with all health and safety requirements and that its staff receive the highest quality training and support.
The company acknowledges the thanks that were offered at the inquest, on behalf of Michelle Gellard’s family, to its duty manager and lifeguards for all that they did to attempt to save Michelle’s life.
The family’s claim has been received and has been passed to our lawyers. We have no further comments to make at this stage.
Investigation
Bob Boyce, the Leader of Maldon District Council and Fiona Marshall, chief executive of Maldon District Council gave several statements summarised below (London Evening Standard, May 2011; Burton, 2012; Cornell, 2008; Mayhew, 2013; BBC News, June 2008):
The council is undertaking a thorough investigation into this tragedy and has been co-operating with the HSE and the Police. The council investigation is to establish whether there were any breaches of health and safety legislation which could have contributed in any way to the death of Michelle Gellard. The council is therefore unable to comment further at this time.
Mr Farrant left his post as CEO of Leisure Connections in early 2009. He has not been involved in the investigation or hearing and therefore cannot comment on the detailed findings or the outcome.
A petition urging people to ensure that lessons are learnt has been created online. Paul Burns ran a site called Leisure Connection Watch which followed up complaints about poor standards in two leisure centres managed by Leisure Connection (Burton, 2011):
This loss of life and persistent pattern of insufficient lifeguards happened on Mr Farrant’s watch. He walked away from the company not long after the drowning. I do not see why he should be entrusted with a major public role when his leadership did not prevent this scandal.
At the inquest into Michelle’s death, the jury returned a verdict of accidental death. Yet in May 2010, there was another incident of a near-drowning involving a young girl swimming at the same pool. This incident prompted the Health and Safety Executive to serve an enforcement notice against the swimming pool.
The inquest has concluded that Michelle’s death was accidental but someone must be held accountable. Michelle’s tragic death should not be in vain.
Charging decision (23 August 2012)
The HSE announced it was prosecuting Leisure Connection Limited on 23 August 2012 for breaching s.3(1) HSWA 1974. The HSE confirmed it would not be taking any action against Maldon District Council and had informed the council about the prosecution.
The council said it was aware of the legal action but would not be commenting further until after the process was completed. Leisure Connection also said it would not comment until the litigation process had concluded (BBC News, August 2012).
Graham Farrant was the CEO of Leisure Connection between 2004 and 2008; leaving shortly after Michelle Gellards death in June 2008 (Mayhew, 2013). He became the CEO of the London Borough of Barking and Dagenham in July 2011; 13 months before Leisure Connection were formally charged in August 2012. When Leisure Connection was formally charged, calls were made public for his resignation from his post at Barking and Dagenham Council. Mr Farrant did not comment on calls for his resignation but said (Mayhew, 2013; BBC News, June 2008):
This tragic incident struck us all hard at the time and my sympathies remain with Michelle’s parents who lost their daughter. All our thoughts and sympathies are with the family and I will do anything we can to help the police investigate this tragic incident. We worked closely with the police investigation and the local council.
R v Leisure Connection Limited (2012) (9 October, Chelmsford Crown Court)
Leisure Connection Limited appeared at Chelmsford Magistrates’ Court charged with a single count of breaching s.3(1) HSWA 1974 (Brooke, 2013; BBC News, August 2012). Leisure Connection pleaded not guilty and the case was allocated for trial at Chelmsford Crown Court in October 2012.
Leisure Connection Limited appeared at Chelmsford Crown Court on Monday, 29 October 2012. It was at the Crown Court that the company changed their plea to guilty. The case was adjourned to allow the parties to prepare ahead of Newton and Sentencing hearings which would return to Chelmsford Crown Court in 2013 (Brooke, 2012).
At the Newton hearing, which is a short trial for the judge to make findings on the factual elements of the offending relevant to the determination of the sentence the judge will then pass, evidence was presented of the site’s performance in recent safety audits. The site had received 80% on its recent health and safety audit and 86% for pool safety. The court was also told that Leisure Connection’s threshold for intervention by the regional team was 70% (3 August 2007).
The court was told that Ms Beckie Sanders, the Contract Manager with responsibility for Blackwater Leisure Centre as one of the sites in the contract, had been in post since June 2007; a year prior to the accident (FOI disclosure). HHJ David Turner QC said as he sentenced Leisure Connection (BBC News, July 2013; Brooke, 2013):
If Michelle had been seen in time it might have made a difference, it might not. It is impossible to say. The poolside manager had reduced the lifeguards to two and that was wrong. Leisure Connection failed to comply with the normal operating procedures available at the site, allocating insufficient lifeguards to ensure swimmers’ safety by providing lifeguards with a full view of the pool. The procedures in place were inadequate.
The company was fined £90,000 and told to pay prosecution costs of £101,663.
Statements following the conviction of Leisure Connection at trial
Mr Mark Gellard said (Cornell, 2008; Maldon Standard, 2011; BBC News, 2013):
Sian and I are devastated that our beautiful daughter Michelle died as a result of this incident. We wanted to know why the lifeguards at the pool appear not to have noticed that Michelle was drowning despite the fact the pool was not busy at the time.
We also wanted to know why the staff at the leisure centre failed to report in the first emergency call that it was a drowning incident and said Michelle was ok and conscious when in fact she required emergency resuscitation. As a result, emergency medical help was delayed which may have lost the chance to save her life.
Life is still very difficult without Michelle and we are still grieving for our daughter. She was our pride and joy. She always brought a smile to our faces and it is hard knowing we will never again get to hold our daughter and tell her that we love her. She is dearly missed by all the family and in our thoughts every day. She will never be forgotten.
It is essential that lessons are learned so this does not happen to anyone else. We do not want this to happen to another child. It the most heart-breaking thing to go through and we hope that lessons are learnt from this.
HSE inspector Antonina Drury said (Heart, 2013; ITV News, July 2013; Brooke, 2013):
This tragic and untimely death should never have happened. Members of the public visiting leisure centre swimming pools have an entitlement to expect that the operator paid to run them will deploy and train its staff so as to provide sufficient numbers of lifeguards in the right places so as to operate the pool safely.
In this case, Michelle Gellard was robbed of her chances of rescue and survival by Leisure Connection's failures. Evidence emerged in the course on the investigation that Leisure Connection failed to identify and address the fact that the amount of lifeguarding it was paying its staff to provide at Blackwater Leisure Centre was noticeably less than the amount it knew was required for the full and safe operation of the pool.
The public is entitled to expect the operator paid to run the centre will provide sufficient lifeguards in the right places to operate the pool safely. Michelle Gellard was robbed of her chances of rescue and survival by Leisure Connection’s failures.
References (65)
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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Citation: Jacklin, D. (2021). Case Summary: Michelle Gellard. Water Incident Research Hub, 31 January.
