Case Summary: Sophie Konderak
Feb 27, 2021CASE SUMMARY
Sophie Konderak was a 16-year-old competitive swimmer who trained at Braunstone Leisure Centre in Leicester. The pool was operated by Leicester City Council. Sophie attended her normal training session with Leicester’s elite performance team at the Centre on Tuesday, 15 September 2009 (BBC News, 2009).
Sophie had a cardiac arrest at around 16:38, shortly after starting her training session (BBC News, 2009). It was later discovered her cardiac arrest had been caused by an undiagnosed heart condition (Dolan, 2010). 23-year-old lifeguard Katy Butler rescued and recovered Sophie to the poolside and conducted CPR for four minutes, supported by her three other lifeguard colleagues who were also on duty (BBC News, 2009; Dolan, 2010; Mail Online, 2009).
Ms Butler was a qualified RLSS UK lifeguard, and although she had never provided CPR in a real-world setting, she had undergone initial and ongoing training as part of maintaining her competency as a lifeguard. Ms Butler incorrectly identified that Sophie had regained normal breathing whilst still unconscious (Dolan, 2010). Ms Butler placed Sophie in the recovery position and waited for the attendance of paramedics. There was an AED available at the site, but it was not used.
Paramedics arrived at around 16:50 and correctly identified that Sophie was still not breathing normally and restarted CPR and used an AED to try to restart Sophie’s heart (BBC News, 2009). One of the lifeguards was reported at the later Coroner’s inquest as having said (Dolan, 2010):
Why are you doing CPR? She is alive.
Sophie’s mum, Lesley Konderak, broke down in tears and cried out (Dolan, 2010):
It is my child’s life, why didn’t anybody do anything? How could you just leave her lying there?
Sophie was transferred by paramedics to Leicester Royal Infirmary but was pronounced dead the same day (Dolan, 2010).
Coroner’s Inquest (2010) (24th February 2010)
Paediatric cardiologist Dr Christopher Duke said (Dolan, 2010):
Sophie’s initial cardiac arrest was caused by an undiagnosed heart condition. Her heart was not restarted by defibrillator until 16:52, 14 minutes after she was rescued from the pool.
It is my opinion Sophie would have survived if she had received continuous CPR. You do not stop resuscitation just because a patient appears to be breathing. You only stop if there is breathing and a pulse.
Ms Butler told the inquest (Dolan, 2010):
I have an RLSS UK National Pool Lifeguard Qualification. I spent four minutes trying to revive Sophie. I thought I had succeeded when she began breathing. If a person is breathing, we are told to stop CPR and put them in the recovery position.
The inquest heard that the “breathing” Ms Butler likely identified was agonal gasps, which is an indication to continue CPR, and not normal breathing which is an indication to stop CPR. The inquest was told that had the AED been attached to the casualty, it would have told Ms Butler to continue CPR as it would not have detected a normal heart rhythm.
Recording a narrative verdict, Catherine Mason, Coroner for Leicester and South Leicestershire, said (Dolan, 2010):
When Sophie became acutely unwell there was a window of opportunity to treat her. Basic life support was given but not continued, in accordance with training. Had CPR been continued, and a defibrillator applied, on the balance of probability she could have survived.
The crucial point of this is that the CPR was stopped. The guidelines should be changed so that from when CPR commences it is conducted until a medically qualified person arrives or the patient regains consciousness.
I will write to the Resuscitation Council UK, which provides guidelines for lifesaving techniques, to ask it to amend its training guidelines to include checking for a pulse.
Response to the incident
Sophie’s parents, John and Lesley Konderak, said (Dolan, 2010):
Sophie was a natural-born water baby and had ambitions to compete in the Olympic swimming team as well as to become a doctor.
The shortfall in the level of training and the equipment available contributed to our daughter’s death. Sophie was the ideal daughter, kind-hearted and loved to swim.
We hope the coroner’s recommendations will lead to an improvement in lifesaving training and no further lives will be lost.
Sophie's former swimming coach, Steve Lay, said (BBC News, 2009):
You never imagine you will get that call and it is the worst kind of news. Immediately, I got the senior swimmers out of the water and told them what had happened and of course, they were quite devastated.
Sophie was a talented teenage swimmer who had dreams of competing in the Olympics. It is incredibly sad.
Another of Sophie’s former coaches, Stuart Henson, said (Daily Star, 2009):
She was one of the fittest swimmers in her age group in the country and was tipped for great things.
Sophie had recently started studying at Leicester’s Wyggeston & Queen Elizabeth I College. The college headteacher, Iain Wilson, said (BBC News, 2009):
She had a reputation as a very hard-working student, also as a very lively girl and very keen to get stuck in here. She had already made her mark, particularly on the sporting front.
Investigation
Braunstone Leisure Centre remained closed the following day as a mark of respect. A police spokesman said (BBC News, 2009; Mail Online, 2009):
Police and ambulance service were called to the Braunstone Leisure Centre responding to reports that a young girl had got into difficulties in the swimming pool.
The girl was taken to Leicester Royal Infirmary where she was pronounced dead. Police are conducting inquiries on behalf of the coroner.
Her death is not being treated as suspicious, but we are questioning pool staff and managers about the tragedy.
Paul Edwards, Head of Sport Services at Leicester City Council (BBC News, 2009; (Mail Online, 2009):
Sophie was rescued from the pool and given first aid but sadly died later in hospital. All of our lifeguards are fully qualified and undergo regular weekly training as part of their role. We will consider our own investigation once the police inquiry was completed.
We will review the statements made by the Coroner and will support any changes proposed to national guidelines on resuscitation training in the light of this tragic incident.
Our thoughts and sympathies go out to Sophie's family and friends at this most difficult time.
Resuscitation Council UK has, to date, made no amendment to its protocol to include the checking of a pulse, stating that this is inconsistent with current best practice for those providing CPR in the community, such as lifeguards and first aiders. The Resuscitation Council make regular updates to CPR guidelines, the last major update being in 2015, and align its guidance with international best practice such as that provided by the European Resuscitation Council. RLSS UK continues to align all of its courses and qualifications, which include the provision of CPR, to the guidance provided by Resuscitation Council UK.
To date, no charges have been brought, and there have been no further updates on the investigation for a considerable period (indicating that it is unlikely that any action will be taken).
References (8)
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 News. (2009). Girl’s pool death investigated. (16th September, 17:43). Available at: http://news.bbc.co.uk/1/hi/england/leicestershire/8258496.stm accessed 2nd February 2021.
BBC News. (2009). Pool death girl’s Olympic dream. (18th September, 11:26). Available at: http://news.bbc.co.uk/1/hi/england/leicestershire/8262535.stm accessed 2nd February 2021.
BBC News. (2010). Swimmer could have survived at Leicester pool. (25th February, 11:36). Available at: http://news.bbc.co.uk/1/hi/england/leicestershire/8535486.stm accessed 2nd February 2021.
Daily Star. (2009). Swim girl tragedy. (17th September, 10:57; first published 17th September, 00:00). Available at: https://www.dailystar.co.uk/news/latest-news/swim-girl-tragedy-18103573 accessed 2nd February 2021.
Dolan, A. (2010). Girl swimmer, 16, died after wrongly trained lifeguard stopped CPR thinking she had saved her life. (Mail Online, 25th February, 20:52; first published 11th March, 00:00). Available at: https://www.dailymail.co.uk/news/article-1253701/Girl-swimmer-16-died-wrongly-trained-lifeguard-stopped-CPR-thinking-saved-life.html#ixzz0huID7EXc accessed 2nd February 2021.
Funeral Notices. (2009). Sophie Konderak. (19th September, 00:00). Available at: https://funeral-notices.co.uk/notice/Sophie+Konderak/2306413 accessed 2nd February 2021.
Mail Online. (2009). Girl, 15, drowns in public swimming pool. (16th September, 12:09). Available at: https://www.dailymail.co.uk/news/article-1213862/Girl-15-drowns-public-swimming-pool.html accessed 2nd February 2021.
The Telegraph. (2010). Swimming girl died after lifeguard stopped CPR. (26th February, 07:30). Available at: https://www.telegraph.co.uk/news/uknews/7317473/Swimming-girl-died-after-lifeguard-stopped-CPR.html accessed 2nd February 2021.
Citation: Jacklin, D. 2021. Case Summary: Sophie Konderak. Water Incident Research Hub, 27 February.
