Holst v. Life Time Fitness, Inc., et al

Date: April 15, 2010

On June 13, 2008, Jana D. Holst and her two children, 4-year-old Colin and Kayla, met their friends to go swimming at the Life Time Fitness Center, located at 7101 South MoPa Expressway, in Austin, Texas, after picking up Kayla from her day camp at that facility. The Holst family were not members of the Life Time Fitness Austin Club, but were there as guests of their friends who were club members.

After a lifeguard break, while the mothers were sitting in lounge chairs under one of the umbrellas on the west side of the pool, the children returned to the water. Jana was watching Colin from her chair, but the zero-entry depth pool had a Mushroom Splash Attraction that likely blocked Jana’s view of Colin at a certain point in time. Minutes passed from when they had last seen Colin swimming to when they heard the whistles.

At approximately 5:24 PM, the Security camera located on top of the building shows Colin entering the multi-attraction family pool at the section of the zero foot entry and progresses towards the Mushroom Splash Attraction. He then progressed a few feet further toward the East side and center of the pool at which time he began having difficulty and then began splashing frantically in distress. His entry, progression, and distress were all captured by the outdoor surveillance camera.

None of the lifeguards stationed on the Peninsula elevated lifeguard stand, the west side Griff stand, or the Kiddy Pool station observed Colin’s progression into the water; his initial signs of an active struggle at the surface of the water; or his deterioration to a passive victim floating at the surface, or his submersion under the surface of the water. The relief lifeguard who was on the deck did not observe any of this either. Although there was supposed to be a Lifeguard Supervisor on the pool deck, he was inside the building at this time. A total of 6 minutes and 35 seconds was documented from the initiation of Colin’s struggle to the time that Lifeguard W, with the assistance of a patron, removed Colin from the water.

At the time of the incident, there were seven (7) lifeguards on duty. However, with over 80 patrons in the water, only two (2) lifeguards were actually assigned the responsibility of guarding the majority of the swimming facility. Two (2) other lifeguards were dedicated to the dispatch and exit of the large slides, and one (1) lifeguard was assigned to the Kiddy Slide station.

• Lifeguard W relieved Lifeguard M at the west side Griff stand and was positioned at that stand from 17:26:27 to 17:32:06 when she left that stand in an attempt to lift Colin out of the water onto the pool deck.

• Lifeguard M rotated to the Kiddy Slide from the west side Griff stand. His responsibilities while at that slide included assisting children up and down the slide – an intrusion upon his public safety and patron surveillance responsibilities for the rest of the swimming pool and its patrons.

• Lifeguard BS was positioned in the elevated lifeguard stand located on the Peninsula. He had a bird’s eye view of Colin’s entire progression from entry to submersion. Lifeguard BS may have been at the Kiddy Slide prior to assuming responsibility of the Peninsula lifeguard stand. Assuming Lifeguard BS was previously assigned to the Kiddy Slide, he would have been rotated from that position at 17:27:15 and would have assumed the position at the Peninsula stand at approximately 17:27:30. However, Lifeguard CE would have been in that stand from the onset of Colin’s entering the water at 17:24:42 to approximately 17:27:30 when he was relieved by Lifeguard BS.

• Lifeguard EC was stationed at the top of the slide and was primarily responsible for dispatching sliders down the slides.

• Lifeguard CE had previously been station on the Peninsula elevated lifeguard stand, but at approximately 17:27:30 he was relieved from that position when he rotated to the bottom of the slides at which time he was primarily responsible for patrons exiting the slides.

• Lifeguard KW had just been relieved from his position at the top of the slides and was on break, on the deck.

• Assistant Aquatics Department Head/Lifeguard Supervisor SEC was inside the building and was not on the deck providing patron safety and surveillance, or supervising the lifeguard personnel.

• The Aquatics Department Head, Erin Slade, was not on duty or at the facility on the date of Colin Holst’s submersion incident.

The lifeguards at the outdoor Life Time Fitness pool failed to observe Colin progress from the zero depth entry section of the pool to the 3’6″ section of the pool as he deteriorated from playing, to active struggling at the water’s surface, to a passive state floating and not moving, to submersion. This progression lasted for a period of close to 8 minutes.

According to Lifeguard W, she had been scanning the pool when she saw a small child in the water. She thought he was playing, so she continued scanning. When she came back to where the child was, she saw he was not moving. According to Wills she then jumped in and pulled the child out. At the time of this incident, Colin was 41″ tall, and he was removed from a water depth of 3’6″ (42″).

When Lifeguard W recognized Colin’s distress at approximately 17:30:30, she alerted another adult patron (Christine Simmons) to investigate Colin’s passive condition in the water. According to Christine Simmons, she had been in the pool with her child and heard a lifeguard blow a single whistle blast. She looked up at the lifeguard in the stand and saw she was looking at something in her direction. She followed the gaze down and observed the victim floating face down in the water.

Ms. Simmons was very close to the victim and told the lifeguard she would check on him. When she reached out and grabbed him at 17:31:57, she saw he was motionless and then flipped him over on to his back. She observed that the child was cyanotic and was wearing goggles. Lifeguard W then stands up while in the West side Griff stand and then vacates the stand at 17:32:06 in order to remove Colin from the water. The video record confirms that although Colin was floating, face down, for several minutes, starting at the East-middle portion of the pool, Lifeguard W did not move from her seat to retrieve him until he had floated in an arc all the way across the pool until he was only a few feet from the West side of the pool.

Lifeguard W, with Ms. Simmons’ assistance, pulled Colin from the water and then sat on the deck with Colin sitting in her lap with his back to her. Wills then rocked and held Colin and blew her whistle until other lifeguards responded and took over care for Colin. Notably, Lifeguard W did not initiate CPR or any basic life support procedures, nor did she ever perform CPR or any basic life support procedures on Colin, despite being the primary rescuer.

Lifeguard M, who had been stationed at the Kiddy Slide, ran over to assist. At least 20 additional seconds passed before he was able to get on scene. Lifeguard M conducted a primary survey of Colin and determined he was cyanotic, and in respiratory and cardiac arrest.

Lifeguard EC had been stationed at the top of the slides when she heard 3 whistle blasts. She saw Lifeguard W sitting on the deck of the pool holding a child. She then slid down the slide and ran to the victim where Lifeguard M was already performing a primary survey.

Lifeguard M and Lifeguard EC then initiated CPR. After several cycles Jamie Slaughter, a pool patron and licensed paramedic, approached and offered his assistance.

Lifeguard BS had been positioned in the elevated lifeguard stand on the Peninsula. After blowing his whistle and clearing the pool, he ran for the backboard, but someone had already retrieved it. He then ran to the incident scene and saw CPR in progress. He then called 911 and ran to the front desk to get the Manager on Duty.

Jaime Slaughter had been swimming laps in the outdoor swimming pool when he saw the lifeguards huddled over someone on the deck. He walked over to the scene and witnessed CPR in progress by two lifeguards. He then offered to assist and took over rescue breathing.

According to Slaughter, the child was unresponsive, cyanotic, and his pupils were fixed and dilated. He inquired whether 911 had been called and whether or not an AED was available. He was told 911 had been called and that the defibrillator was on the way.

Slaughter attempted to provide positive pressure ventilation to Colin, but Colin’s airway was compromised with water and vomitus. Several attempts were made to clear his airway.

Lifeguard CE had been at the slide exit when he heard the whistles. He got out of the water and went to the incident scene where he saw CPR being performed. He then went to locate Assistant Aquatics Department Head SEC. SEC told Lifeguard CE to retrieve an AED. However, the AED that Lifeguard CE brought to the scene wasn’t operational and Lifeguard EC stated she thought it was a Training AED. When Supervisor SEC responded to the scene, he was approached by Lifeguard W who told her what transpired.

Lifeguard KW had brought the backboard to the scene and then ran to get the AED from “inside the gym” and “made my way back to the pool in full sprint.” But, by the time he got back to the scene, EMS had already arrived.

Police, Fire and EMS units were dispatched for a possible child drowning in the pool at Life Time Fitness.

Colin was transported to Dell Children’s Hospital.

The following day, June 14, 2008, Colin was pronounced deceased at 4:05 PM.

LIFETIME FITNESS AQUATICS MANUAL
Updated December 2006

The manual states the objective of the department is “to provide safety and fun by being attentive, alert, and responsive to the needs of our Members at all times.” The manual then lists behaviors for achieving the department objectives, including:

• Adheres to the 10/20 rule
• Respects and adheres to the 5-minute rule
• Is always attentive to members and surroundings

Lifetime Fitness Aquatics Departments

Lifetime Fitness claims that “our facilities offer the most advanced Aquatics Departments with the most innovative models of pools and equipment” and that “the Aquatics Department provides each member with a safe and clean facility.”

The Lifetime Fitness Brand

The manual also discusses the Lifetime Fitness (LTF) brand and that “the Aquatics Department upholds the LTF brand by adhering to LTF brand guidelines” and that “the Aquatics Department supports the LTF brand by offering a safe and enjoyable aquatics experience.”

Aquatics Department Organization Structure

According to the manual, the Assistant DH, Supervisor, Lifeguard and Attendant are all on an equal plane reporting to the Aquatics Department Head.

Aquatic Team Member’s Role and Responsibility

Aquatics Department Head
• Maintains the day-to-day operations of the Aquatics Department
• Training and development of staff
• Helping to maintain the safety, function & cleanliness of the aquatic center
• Serves as supervisor on deck during family hours

Assistant Aquatics Department Head
• Assists Aquatics Department Head in day-to-day operations
• Training and development of staff
• Helping to maintain the safety, function & cleanliness of the aquatic center
• Serves as supervisor on deck during family hours

Lifeguard
• Knowledge of Red Cross certifications
• Assists in providing a safe, fun, and clean environment & experience to all members during Family hours.

Aquatics Department Certifications

Aquatics Department Head
• ARC Lifeguarding
• ARC CPR/AED for the Professional Rescuer
• Certified Pool Operator
• ARC Lifeguard Instructor (strongly recommended)
• ARC Lifeguard Instructor Trainer (recommended)
• Aquatic Facility Operator (recommended)

Assistant Aquatics Department Head/Supervisor
• ARC Lifeguarding
• CPR/AED for the Professional Rescuer
• Certified Pool Operator (recommended)
• ARC Lifeguard Instructor (recommended)
Lifeguard
• ARC Lifeguarding
• ARC CPR/AED for the Professional Rescuer

The Role of the Aquatics Department Head

The manual states, “the highest priority is in the casting, training, and developing of your Aquatics Team Members.”

Aquatics Department Forms

Lifeguard Rescue Report: used when a rescue is completed where a lifeguard must aid someone in the water. An incident report must be completed in addition to this form. This form is used by the lifeguard performing the rescue and is turned into the Aquatics Department Head.

Incident Report: report is completed for any incident involving an injury to a Team Member or Member, no matter how small.

LIFETIME FITNESS EMPLOYEE RELATIONS MANUAL
Updated: December 2006

Lifeguard Rotations

In order to ensure that the Lifeguards stay “fresh” at their position, we rotate every 15 minutes.

There are seven (7) possible locations or tasks for guards:
1. Chair 1
2. Chair 2
3. Chair 3
4. Chair 4
5. Slide Top
6. Slide Bottom
7. Cleaning

Your Aquatics Department may have more or less than seven stations depending on size and demand.

Lifeguard In-Service

It is a Life Time Fitness requirement that all Aquatics Staff attend a minimum of one-hour of In-service Training each month.

Rescue Report

A Rescue Report is completed when a lifeguard must aid someone in the water. An incident report must be completed in addition to this form. This form is used by the guard performing the rescue and is turned into the Aquatics Department Head.

Incident Report

This (form) is used for the smallest first aid.

Emergency Procedures

Life Time Fitness is prepared in the event of any emergency. There are emergency procedures for the following events:

• Injury
• Power Outage
• Flooding
• Death
• 911
• Fire
• Tornado

Team Member Expectations

It is expected that you will meet a high level of expectations for everything from your dress to the quality of service you deliver to the Members and Guests.

Guarding

As lifeguards we do not babysit children, we protect them from dangers. Our primary job as lifeguards is to PREVENT accidents from happening, while still allowing the Members to enjoy themselves.

• We watch the pool with unwavering attention and diligence.
• We attend all In-service training to keep our skills up-to-date.

Education

• We keep our guard skills up-to-date by attending In-service trainings
• First Aid and Lifeguard Certification
• We keep all our certifications up to date.

Standard of Care

Effective January 2004 Life Time Fitness recognizes the American Red Cross Training Program as the “standard of care” for the Aquatics Department. As a Team Member, you are required to be knowledgeable in the standards set by the American Red Cross.

In-Service Sign-In Sheet

Each Aquatics Team Member is required to attend In-service Training. In order to track attendance at these events we have created a sign in sheet.

Chair Etiquette

Chair etiquette is important to the perception of Members and the completion of our guarding and risk management tasks (and include):

1. 5-minute rule: Are the guards making a substantial posture change every 5-minutes while in the stand?

2. 10/20 rule: Are the guards capable of recognizing a victim in 10 seconds and then getting to and rescuing them in 20 seconds?

3. Rescue Tube Placement: The rescue tube should be easily accessible at all times.

4. Posture and expressions: Guards should always sit/stand up straight in the chair.

Slides

Slide rules listed on the aquatic facility rules should be strictly followed. The slide landing area should be kept clear at all times so that slide users have an unobstructed place to exit the slide. The slides should only be operated when there are two lifeguards on duty. One to guard the pool, and one to risk manage the slide.

Whistle Codes

1 long whistle blast: Clear the pool for an emergency

1 short whistle blast: Get the attention of a member

2 short whistle blasts: Get the attention of another guard/supervisor/DH

Aquatics Department Emergency Action Plan

1. Guard (primary rescuer) determines a rescue is required and blows one long whistle blast to alert other guards and begin clearing the pool. Guard enters the pool to make appropriate rescue.

2. All other guards join in blowing one long whistle blast and continue clearing the pool. If a secondary rescuer is needed the guard to the right of the primary rescuer becomes the secondary rescuer and assists appropriately.

3. If EMS needs to be called, the guard to the right of the secondary rescuer calls EMS and notifies them of the rescue situation, the location, and then goes to the front desk and has the front desk page “Code 100 all managers to the accident site” over the paging system.

4. The primary and secondary rescuers continue giving appropriate care until EMS personnel arrive. Once EMS personnel arrive a rescue & incident report is filled out. Witnesses are interviewed and their statements written down. If needed a staff debriefing will be scheduled by the DH.

In-Service Training

It is a LIFE TIME FITNESS requirement that all Aquatics Team Members attend a minimum of one hour of In-Service Training each month. The following in-service topics are identified in Chapter 3:

• Responsibilities, Scanning, Surveillance, Rotations, and EAP
• Preventive Guarding
• Review of Rescue Skills and Swimming Skills
• Disease Transmission & First Aid
• Rescue Breathing & Choking
• CPR
• Aquatics Department Objectives, Customer Service
• Spinal Injuries – Shallow and Deep Water
• Emergency Procedures
• Sexual Harassment
• Lifeguard Jeopardy
• Scenarios
• Lifeguard Olympics

The plan is to hold at least one In-service each month. At the end of the twelve In-services, Team Members will have successfully reviewed and recertified themselves in Lifeguarding and CPR-PR provided that they pass the final scenarios in In-service 12.

Guard Critique Sheets

Guard critique sheets are used to monitor and review guard performance while in the chair as a risk management tool. The sheet addresses, among other things:

• Proper Rotations
The guard watching the water should have the tube in their hands at all times.
• 5 Minute Rule
Are the guards changing positions on the stand every 5 minutes to stay alert.
• Proper Scanning

Are the guards scanning the entire area consistently? Make sure they are moving their head with their eyes and are not focusing on one area too long.
• Posture on Stand
The way the guard is sitting on the stand. Do they look alert and are they smiling at or engaging Members in a positive way?

Job Descriptions:

Aquatics Department Head

Maintains day-to-day operations of the pool providing a safe and clean environment…. Ensures adherence to safety…standards. Responsible for the overall direction, coordination, and supervision of the Aquatics Department team members. Examples of work performed includes:

• Provides staff training on pool safety
• Maintains systems book on monthly basis
• Recruits, interviews, and trains new team members
• Provides effective performance evaluations
• Supervises assigned team members

Assistant Department Head

Assists the Department Head in maintaining day-to-day operations of the pool by providing a safe and clean environment…. Assists the Department Head in the overall direction, coordination, and supervision of the Aquatics Department team members through recruiting, casting, training, and developing. May act as department head in the Department Head’s absence. Examples of work performed includes:

• Maintains a safe and clean work area at all times
• Assists the DH in providing staff training on pool safety scenarios & Customer Service
• Helps maintain the systems book on a monthly basis
• Assists in training and developing team members
• Assists in recruiting, interviewing and training new team members
• Helps provide effective performance evaluations
• Supervises assigned team members

Supervisor

Monitors activities in swimming areas to prevent accidents and provide assistance to swimmers ensuring the overall safety of the pool area. Examples of work performed includes:

• Maintains order in swimming areas
• Cautions swimmers regarding unsafe areas
• Rescues swimmers in danger of drowning and administers first aid
• Supports lifeguards by serving as supervisor on deck when the DH is absent
• Ensures incident reports are completed correctly and submitted
• Supervises staff while DH is out of the office
• Assists DH in completing Guard Critiques Sheets on lifeguard performance

Lifeguard

Assists in providing a fun, safe, clean environment and experience to club members during family hour. Monitors activities in swimming areas to prevent accidents and provide assistance to swimmers ensuring the overall safety of the pool area. Examples of work performed includes:

• Maintains order and safety in swimming areas
• Cautions swimmers regarding unsafe areas
• Rescues swimmers in danger of drowning and administers first aid

Pool Rules

• Children 12 years of age are only allowed in the pool area during Family Hours when accompanied by a parent or legal guardian.

• A parent or legal guardian must accompany children 12 – 15 at all times.

• There is an enforced limit of 3 children per 1 supervising adult.

• Children must be directly supervised at all times; parents must be present in or near the same body of water as the children.

• Coast Guard approved flotation devices may be used

• Safety Breaks will be held every hour on the hour during Family Hours.

• Children (15 and under) on the pool deck unattended:
Parents will be immediately paged and told of the rules

LIFEGUARD TEAM MEMBER TRAINING: AQUATICS
POWERPOINT PRESENTATION

What is the Aquatics Department Objective?

Provide safety and fun by being attentive, alert, and responsive to the needs of our Members at all times.

How do we deliver the Aquatics Department Objective?

• All Team Members must attend monthly in-services and meetings
• All Team Members must follow safe preventative guarding practices

Guarding

As an Aquatic Team Members, we each take on the role as Lifeguard. As lifeguards we do not baby-sit children, we protect them from dangers. Our primary job as lifeguards is to PREVENT accidents from happening. We work everyday to present a safe and clean pool to each and every Member that enters the pool area.

• We watch the pool with unwavering attention and diligence
• We correct and redirect Members to protect them and their children

Chair Etiquette

1. 5-minute rule: Are the guards making a substantial posture change every 5 minutes while in the stand?

2. 10/20 rule: Are the guards capable of recognizing a victim in 10 seconds and then getting to and rescuing them in 20 seconds.

3. Rescue Tube Placement: The rescue tube should be easily accessible at all times.

4. Posture and expressions: Guards should always sit/stand up straight in the chair.

Guard Critique Sheets Explanation and Usage

Guard Critique sheets are used to monitor and review guard performance while in the chair as a risk management tool. Things that are critiqued include:

1. Proper Uniform and Presentation

2. Proper Rotations: The procedures are explained within the section. Simply put, the guard watching the water should have the tube in their hands at all times. A rotation schedule should be in place planning where and when guards should rotate – keeping in mind that based on bather load this may change.

3. 5-Minute Rule

4. Proper Scanning: Are the guards scanning the entire area consistently? Make sure they are moving their head with their eyes and are not focusing on one area too long.

5. Posture on Stand

6. Appropriate Rule Enforcement: Based upon the rules set up by LTF, are they fairly and consistently correcting Members on the rules and are they managing the grey areas appropriately.

Whistle Codes

1 Long Whistle Blast = Clear the pool for an emergency

1 Short Whistle Blast = Get the attention of a member

2 Short Whistle Blasts = Get the attention of another guard/supervisor/DH

Hand Signals

Arm above head in a fist – needs assistance from guard not on stand

Emergency Action Plan (EAP)

1. Guard determines a rescue is required and blows one long whistle blast to alert other guards and begin clearing the pool. This guard then becomes the primary rescuer and enters the pool to make the appropriate rescue.

2. All other guards join in blowing one long whistle blast and continue clearing the pool. If a secondary rescuer is needed the guard to the right of the primary rescuer becomes the secondary rescuer and assists appropriately.

3. If EMS needs to be called, the guard to the right of the secondary rescuer calls EMS and notifies them of the rescue situation, the location, and then goes to the front desk and has the front desk page “Code 100 all managers to the (accident site)” over the paging system.

4. The primary and secondary rescuers continue giving appropriate care until EMS personnel arrive. Once EMS personnel arrive a rescue & incident report is filled out. Witnesses are interviewed and their statements are written down.

Lifeguard Rescue Report

Used when a rescue is completed where a lifeguard must aid someone in the water. An incident report must be completed in addition to this form. This form is used by the lifeguard performing the rescue and is turned into the Aquatics Department Head.

Make sure you are very detailed in your description of the rescue and that you fill out all pars of the rescue report.

Incident Report

This report is completed for any incident involving an injury to a Team Member or Member, no matter how small.

OPINIONS & BREACHES IN THE STANDARD OF CARE

BREACHES IN THE STANDARD OF CARE

1. Failure of LTF Austin to assess the knowledge and skill level of lifeguard personnel.

Although LTF Austin interviewed lifeguard candidates, they were not required to demonstrate skill and/or knowledge competency and proficiency of lifeguarding principles and procedures, first aid or CPR.

2. Failure of LTF Austin to assess lifeguard operational and surveillance capabilities of lifeguard personnel.

LTF Corporate advocated several operational standards regarding lifeguard surveillance protocols and procedures, including the 10/20 Rule and the 5-minute Scanning protocol. They also provided a Lifeguard Critique sheet to be used by the supervisor on deck to evaluate their lifeguard personnel. However, there is no documentation that was required by LTF Corporate, and no documentation that was produced by LTF Austin to show that, prior to this incident, efforts were made to assess the lifeguards’ operational and surveillance capabilities of the lifeguards who were on duty at the time Colin drowned.

3. Failure of LTF Austin to position lifeguard stands and personnel as indicated in corporate SOPs.

According to the Zones of Responsibility Charts provided to LTF Austin by Life Time Fitness, the number of lifeguards on duty providing surveillance to patrons, based on the number of patrons in the water, should have been 6 plus 1 on-deck supervisor. However, during the time of this incident, there were only 5 lifeguards on duty assigned surveillance responsibilities and there was no on-deck supervisor present.

Furthermore, the positioning of the lifeguard personnel based on the LTF charts showing the Zones of Responsibility showed the placement of the Griff Lifeguard Stand on the southwest section of the pool, rather than on the west side of the pool. The placement of the lifeguard stand on the west side of the pool did not allow for the lifeguard in the Griff stand to see the transition point where the water goes from a depth of 2’11”, as marked on the deck to a depth of 3′ 6″, where Colin first got into trouble. The placement of the Mushroom Splash Attraction also caused visual blockage of the Griff stand on the west side.

Placing the Griff stand on the southwest section of the pool would have provided a much more effective and strategic view of the patrons in the pool.

LTF Corporate representatives were fully aware of the placement of the Griff stand on the west side wall, rather than the southwest wall, and failed to correct or intervene to position the stand where LTF had intended that stand be placed.

4. Failure of LTF Austin to post a lifeguard at the Beach entry.

According to the protocols established by LTF Corporate, based on the number of patrons in the pool at the time of Colin’s submersion incident, there should have been 6, rather than 5, lifeguards providing surveillance. And, the 6th lifeguard should have been positioned at the Beach Entry section of the pool on the north side.

Had a lifeguard been stationed at the beach entry section, that lifeguard would have been able to observe Colin entering the water and his progression into deeper water.

5. Failure to adhere to LTF Corporate Best Practices pertaining to lifeguard operations.

LTF Corporate specified the number of lifeguards required for patron surveillance, based on the number of patrons using the facility; the placement of lifeguard stations; the need to maintain continuous in-service training; and they provided the tools to evaluate the lifeguard personnel, as well as to critique an in-water incident.

Yet, LTF Austin failed to appropriately position the lifeguard stands; they failed to post the required number of lifeguard personnel, based on the number of patrons in the water; they failed to document in-service training; they failed to document assessments of lifeguard capabilities; and they failed to develop a Rescue Report at the conclusion of Colin’s incident.

LTF Corporate failed to adequately supervise the operations of LTF Austin, as well as the LTF Austin’s Aquatics Department Head and Assistant Department Head to assure that LTF policies and procedures were being adhered to.

6. Failure of LTF Corporate to require LTF Austin to adhere to LTF Corporate Best Practices pertaining to lifeguard operations.

LTF Austin failed to adhere to patron to lifeguard ratios; lifeguard in-service training requirements; lifeguard station positions; supervision of personnel; assessment of lifeguard capabilities; etc.

LTF Corporate failed to evaluate the capabilities of the LTF Austin Aquatics Department Head and the Assistant Department Head and they failed to monitor the operations of the LTF Austin Aquatics Department.

7. Failure of LTF Corporate to require site-specific pre-service training.

Although LTF Corporate outlined a Lifeguard In-Service Plan, they made no effort to develop and/or require site-specific pre-service training for LTF Austin lifeguard personnel. Although LTF Austin lifeguards may have been “certified” as having successfully completed a Lifeguard Training and CPR for the Professional Rescuer course, there was no requirement to “qualify” the lifeguard personnel for this specific facility.

8. Failure to LTF Austin to conduct site-specific pre-service training.

LTF Austin failed to conduct site-specific pre-service training in order to “qualify” their lifeguard personnel for this specific facility. This was evident by their failure to comply with the stated Emergency Action Plans and/or their failure to know whether the Emergency Acton Plan was the one the LTF Austin lifeguards were supposed to follow. Also, this is also evident by the fact that an AED Trainer or inoperable AED was brought to the incident scene for use on Colin, rather than an operational AED.

9. Failure of LTF Corporate to require LTF Austin or to monitor and evaluate LTF Austin’s ability to provide in-service lifeguard training as intended.

Although LTF Corporate developed a Lifeguard In-Service Training Plan, they failed to monitor and evaluate LTF Austin’s ability to adhere to the Lifeguard In-Service Training Plan.

10. Failure of LTF Austin to document and/or conduct intended in-service training.

LTF Austin failed to maintain adequate records to document the required Lifeguard In-Service Training Program, such as by tracking topics covered and attendance of participating lifeguard personnel. Although LTF Corporate required 1 hour of in-service training to be conducted each month, the State of Texas requires 1 hour of in-service training (4-hours per month).

And, as demonstrated by the lifeguards during their response to Colin’s submersion incident once this incident was finally recognized, it is clearly evident these lifeguards were not appropriately trained, drilled, or knowledgeable about Incident Command, emergency management, or the facility’s Emergency Action Plan.

11. Failure of LTF Corporate to require Bag-Valve-Mask (BVM) Resuscitators for use by lifeguard personnel for response to patients in respiratory and/or cardiac arrest.

Although lifeguard personnel were trained in the use of Bag-Valve-Mask Resuscitators during their CPR/AED for Professional Rescuer certification courses, LTF Corporate did not require LTF Austin to provide this equipment as the appropriate response to patients in respiratory and/or cardiac arrest.

The use of a BVM during the administration of positive pressure ventilation will provide 21% oxygen concentration, whereas, the use of a Personal Resuscitation Mask will only provide 16% oxygen concentration.

12. Failure of LTF Austin to provide Bag-Valve-Mask (BVM) Resuscitators for use by lifeguard personnel for response to patients in respiratory and/or cardiac arrest.

Again, lifeguard personnel were trained and certified in the use of BVM during the administration of positive pressure ventilation, but LTF Austin failed to provide the lifeguards with this lifesaving equipment.

13. Failure of LTF Corporate and LTF Austin to adhere to national resuscitation standards for the response to respiratory and/or cardiac distress and/or arrest patients.

Drowning is a hypoxic event. The most effective way to manage hypoxia is by providing high concentrations of oxygen during the administration of positive pressure ventilation. Yet, LTF Corporate, as well as LTF Austin, failed to recognize the recommendations by the American Red Cross to have lifeguard personnel trained and certified in Oxygen Administration as well as to have this equipment available for the rapid and effective response to patients in respiratory and/or cardiac distress and/or arrest.

Oxygen Administration courses are available through the American Red Cross, the American Safety and Health Institute, the National Safety Council, and Dive Rescue International. These courses include airway management, using a manual hand-held suction device, and oxygen administration using an oxygen tank and regulator, with oxygen delivered via the use of a BVM during positive pressure ventilation.

Furthermore, once Colin was removed from the water by Lifeguard Wills, CPR was delayed for at least an additional 30 seconds, or more, until Lifeguard Morton could respond from across the pool to assess Colin and initiate basic life support CPR.

14. Failure of LTF Corporate and LTF Austin to educate lifeguards on Zones of Responsibility (ZOR) and failure to stipulate specific Z of R.

Although LTF Corporate specified the Zones of Responsibility within their Best Practices material, LTF Austin (a) did not employ these Zones or the intended Lifeguard stations, and (b) failed to educate the lifeguards on their Zones of Responsibility. In fact, when Lifeguard M and Lifeguard W were asked to describe the ZOR for their facility, each lifeguard came up with a different plan, as did the Aquatics Department Head for LTF Austin, and as did the representative for LTF Corporate.

LTF failed to monitor the operations and protocols of LTF Austin and they failed to determine whether LTF Austin was adhering to the ZOR as stated within LTF Corporate materials.

Furthermore, the design of the pools was mandated by LTF Corporate. LTF Corporate failed to provide any delineation markings to aid the lifeguards in identifying their ZOR, which added to the confusion as evidenced during the lifeguards’ testimony.

15. Failure of LTF Corporate to require a lifeline to segregate the changing water depths.

As previously indicated, LTF Corporate designed the LTF Austin pool facility. Had LTF Corporate conducted an appropriate and effective Threat Assessment of their facilities, they would have realized the confusion that existed between the posted depth markers and the actual water depths of the pool. Furthermore, they would have realized the heightened risk young children were at as they progressed into deeper water that was not identified with floor markings and lifelines.

16. Failure of LTF Austin to position a lifeline between the 2’11” and 3’6″ depths of the pool.

LTF Austin should have assessed the hazards and risks associated with the design of their facility, especially to young children, and should have installed a lifeline to serve as a physical barrier between the posted 2’11” water depth and the 3’6″ posted water depth.

Furthermore, they should have realized the need to identify changing water depths with floor markings on the bottom of the swimming pool, which also would have assisted lifeguard personnel in maintaining an effective Zone of Responsibility.

17. Failure of LTF Corporate and LTF Austin to identify the hazards and risks associated with the Mushroom Splash Attraction.

When the Mushroom Splash Attraction was operating, it produced a loud splashing noise and the location of this attraction, especially when it was operational, would block the view of lifeguards while trying to provide supervision and surveillance to children in that area of the swimming pool.

18. Failure of LTF Austin to conduct a Threat Assessment to determine the most strategic position for lifeguard personnel and stations and LTF Corporate failed to monitor the operations of LTF Austin regarding the placement of LTF Austin’s lifeguard stations.

It is the responsibility of every pool owner and operator to conduct a comprehensive Threat Assessment to identify the physical hazards of the facility and behavior risks of patrons. Once the hazards are identified, it is the responsibility of the owner and operator to either remove the hazards or warn patrons about these hazards. Once risk is identified, it is the responsibility of the owner and operator to either safeguard or prohibit the risk.

Had an appropriate Threat Assessment been conducted of this facility, it would have been evident as to the proper location of lifeguard personnel and lifeguard stations, especially when these tools were provided by LTF Corporate.

At the same time, it was LTF Corporate responsibility to be sure LTF Austin was operating as intended in LTF Corporate materials.

19. Failure of LTF Corporate to design the pool with constant depths.

Although the depth marker on one side of the pool would indicate one depth, the actual depth of the water as well as the depth marker on the other side of the pool would not be consistent. And, because there were no lifelines in place or pool bottom markings on the pool bottom, it was very difficult to determine the water depths beyond the zero entry section of the swimming pool. These inconsistent water depths placed young children at heightened risk of drowning and injury.

20. Failure of LTF Corporate to develop a comprehensive Risk Management and Threat Assessment mechanism and plan for LTF Austin.

LTF Corporate materials made reference to Risk Management tools, but they failed to develop and implement a comprehensive Risk Management Plan by the LTF Corporate Aquatics Department and they failed to develop a comprehensive Risk Management Plan for LTF Austin.

21. Failure of LTF Austin to comply with corporate lifeguard-to-patron ratios.

As previously indicated, there were over 80 patrons in the water which would have required a minimum of 6 lifeguards on duty assigned to public safety and surveillance, in addition to an on-deck supervisor. However, at the time of the incident, there were only 5 lifeguards on duty.

Of the 5 lifeguards, 1 was assigned to the Kiddy Slide and 2 were assigned to the dispatch and exit of the large 2-story water slides. Therefore, there were only 2 lifeguards who had public safety and surveillance responsibility for the rest of the pool.

There was no lifeguard stationed at the beach entry section of the pool. There was no on deck supervisor. And, the position of the Griff stand was not in compliance with the stand position as stated within LTF Corporate materials.

22. Failure of LTF Corporate to require LTF Austin to comply with lifeguard-to-patron ratios as indicated in LTF Corporate Best Practices.

LTF Corporate failed to monitor the operations of the LTF Austin facility and they failed to require the LTF Austin facility to comply with lifeguard-to-patron ratios as indicated in the LTF Corporate Best Practices.

23. Failure of LTF Corporate and LTF Austin to require manual hand-held suction devices at the LTF Austin facility, and failure to require training of lifeguard personnel in the use of manual hand-held suction devices.

75% of cardiac arrest victims will vomit during the administration of CPR. However, during the administration of CPR to submersion incident victims, typically 95% or more will vomit, resulting in a compromised airway and difficulty for the rescuer to maintain a patent airway and to perform effective positive pressure ventilation.

As a result, EMS personnel will always respond to a respiratory and cardiac arrest patient with positive pressure ventilation, oxygen administration, AED, and suction equipment.

The use of a manual hand-held suction device is very easy to teach and learn and the cost of this equipment is under $60.

LTF Corporate should have required this equipment. LTF should have developed training and operational protocols for the use of this equipment. LTF Austin lifeguards should have been trained in the use of this equipment. And, LTF Austin should have had at least 1 unit available for use during the resuscitation efforts on Colin, prior to the arrival of Fire and EMS units and personnel.

A trained and certified paramedic was present during part of the resuscitation effort on Colin and could have easily used this, as well as a Bag-Valve-Mask resuscitator, and oxygen administration equipment, prior to the arrival of Fire and EMS units and personnel.

24. Failure of LTF Corporate and LTF Austin to require oxygen administration equipment at the LTF Austin facility, and failure to require training of lifeguard personnel in the use of this equipment.

As previously mentioned, the only effective way to respond to and manage a hypoxic incident is with the administration of a high oxygen concentration during the administration of positive pressure ventilation.

Besides having the training and equipment available for use by lifeguard personnel, a trained and certified paramedic was present during part of the resuscitation effort on Colin and could have easily used this, as well as a Bag-Valve-Mask resuscitator, and manual hand-held suction equipment, prior to the arrival of Fire and EMS units and personnel.

25. Failure of LTF Corporate and LTF Austin to establish inspection and operational practices and protocols for LTF Austin facility’s AEDs, and failure to provide an appropriate number of AEDs for the LTF Austin facility.

Each facility, including the LTF Austin facility, was provided with 2 AEDs. Yet, no protocols were established pertaining to inspection and operations. One of the lifeguards stated during his deposition that he was aware that one of the AEDs was defective. Yet, that AED was allowed to remain available for use, even though it was not operational.

During my site visit of the LTF Austin facility, I found expired pads in one of the AEDs, and the electrode placement of the AEDs was not standardized.

There is some speculation that an AED Trainer was brought to the incident scene, rather than an operational AED. This is an example of the lack of operational protocols for the lifeguard personnel. The AEDs were mounted in alarmed boxes that were designed to trigger a loud audible alarm when the AED was removed for an emergency. If a lifeguard grabbed an AED from some location other than one of the 2 locations identified for the AEDs, and an audible alarm wasn’t triggered when the AED was removed, then it was most probably either a broken AED or an AED Trainer.

Furthermore, for an AED to be most effective, it must be available for use within 2 – 4 minutes of the onset of the cardiac arrest. Two AEDs were available at the LTF Austin facility. One was located in the hallway, across from the entrance into the Men’s Locker room, on the outside wall of the basketball court. The other AED was located upstairs in one of the main workout areas. LTF Corporate and LTF Austin failed to conduct a Threat Assessment to determine the need for and placement of an additional AED within the Aquatics Department facility. Additionally, although Ms. Slade LTF Austin’s Aquatics Director, requested an additional AED for placement within the Aquatics Department, her request was denied. During the site visit, there was one additional AED located within the Aquatics Office within the indoor pool facility.

Lastly, if there was a broken AED, that AED should have been removed from service and immediately repaired or replaced. And, during the site inspection, where an expired set of AED pads were observed, LTF Austin should have immediately removed that AED from service until replacement and current pads could be installed.

26. Failure of LTF Corporate to require lifeguard surveillance, victim recognition, and emergency response drills; and failure of LTF Austin to conduct surveillance, victim recognition, and emergency response drills.

Once Lifeguard W recognized the need to intervene in Colin’s submersion incident, the LTF Austin lifeguards failed to implement the LTF Emergency Action Plan, which demonstrates a lack of training and drills conducted by LTF Austin lifeguards. This lack of training was further demonstrated by conflicting testimony between Lifeguard M and his boss (Slade) as to whether the corporate EAP was in place at LTF Austin on the date of Colin’s submersion incident.

Colin’s distress went unrecognized by the lifeguards for a period in excess of 7 ½ minutes. After Lifeguard W recognized the need to intervene, she began removing Colin from the water prior to alerting the other facility lifeguards of the incident. As indicated in the operational manual, a long whistle blast should have been blown to alert all the lifeguards in the facility of the incident.

After Lifeguard W contacted Colin, she sat on the deck and rocked Colin while blowing her whistle. This “panic” and inappropriate response is indicative of a lack of training. Lifeguard M responded to these whistles and ran to him at which time he conducted a Primary Assessment and initiated CPR. During Lifeguard M’s response, he slipped on the edge of the pool, which could have resulted in injury. Although Lifeguard M was the first to administer CPR to Colin, he was not the Primary Rescuer, nor was he the designated Secondary Rescuer as described within the LTF Emergency Action Plan. And, Lifeguard EC assisted in the performance of CPR, she also was not the designated Secondary Rescuer, as that should have been the responsibility of Lifeguard CE. Again, this is also indicative of the lack of training of the LTF Austin lifeguards and their lack of planning and preparedness to deal with this type of emergency incident.

Even though LTF Corporate included drills within their Lifeguard In-Service Plan, this type of training should have been included as part of the pre-service Lifeguard Training and should have been continuously drilled and evaluated, outside of the LTF Corporate Lifeguard In-Service Plan.

Once the lifeguard staff was alerted to the incident, there was absolutely no coordination of effort, which is indicative of the lack of training of the lifeguard personnel. Lifeguards who were designated as the Primary and Secondary Rescuers, as described within the established Emergency Action Plan did not act accordingly. No lifeguard attempted to retrieve an AED which should have been an automatic part of the rescue effort. Instead, Lifeguard CE went to alert Supervisor/Assistant Department Head SEC, who was inside the building at the time of the incident. SEC then directed Lifeguard CE to retrieve an AED. And, once SEC responded to the incident, he failed to assume Incident Command to coordinate the entire rescue process prior to the arrival of EMS personnel. Again, this is clearly indicative of the lack of lifeguard site-specific pre- and in-service training and their failure to conduct emergency response drills.

27. Failure of LTF Corporate and LTF Austin to require Aquatics Department Head and Assistant Department Head to participate in an American Red Cross Lifeguard Management training program.

Although LTF Corporate states, “effective January 2004 Life Time Fitness recognizes the American Red Cross Training Program as the standard of care for the Aquatics Department”, there is no mention in any of their materials about the American Red Cross Lifeguard Management training and certification program. This program is designed specifically for lifeguard managers and supervisors, yet LTF Corporate and LTF Austin failed to require or even recommend this training for the Aquatics Department Head and the Assistant Department Head.

28. Failure of LTF Austin to recognize Colin’s distress as an active drowning victim.

According to the security camera video, the onset of Colin’s distress was initiated at 17:25:31 and he continued to show signs of an active struggle until approximately 17:27:17. My review of the video with super-imposed Zones of Responsibility confirms that the lifeguards in the Peninsula Chair and West Griff Chair should have seen Colin in distress during a minimum of 21 scans (10 from the Peninsula Chair and 11 from the West side Griff Stand) during that time. Inexplicably, no rescue was initiated or even attempted.

29. Failure of LTF Austin to recognize Colin’s distress as a passive drowning victim.

At 17:27:17 Colin does not show any signs of struggling and was, at that point, what is considered to be a passive victim. No intervention was provided by the lifeguards until Lifeguard Wills directed an adult patron to check on Colin at approximately 17:31:57, a period of greater than 4 ½ minutes. My review of the video with super-imposed Zones of Responsibility confirms that the lifeguards in the Peninsula Chair and West Griff Chair should have seen Colin in this passive drowning state during a minimum of 40 combined scans during these 4 ½ minutes. Again, it is inexcusable that no rescue was initiated or even attempted during this time.

30. Failure of LTF Corporate and LTF Austin to prevent lifeguards from engaging in activities that intrude upon their patron surveillance and public safety responsibilities.

During busy family swim hours, 1 lifeguard was always assigned to the Kiddy Slide. While at that station, that lifeguard is responsible for supervising and assisting young children in climbing up and sliding down this slide. This is an activity that intrudes upon the lifeguard’s surveillance and public safety responsibilities for the rest of the pool, and specifically, their assigned Zones of Responsibility.

31. Failure of LTF Corporate and LTF Austin to implement appropriate Layers of Protection required to safeguard young children at their facility.

Layers of Protection are designed to be implemented to prevent children from accessing bodies of water that pose a hazard, risk or danger to the child. In this case, there were inadequate Layers of Protection that were implemented. There were no lifelines in place and there was no lifeguard positioned at the zero-entry depth section of the pool. And, although the Mushroom Splash Attraction is a fun feature, it is noisy and it impedes the ability of the lifeguards and parents to effectively supervise young children in and around that feature.

32. Failure of LTF Corporate and LTF Austin to train lifeguard personnel in Incident Command principles as part of their Emergency Response Training.

Not only was the recognition of this incident deficient, but the response by the lifeguard personnel was very uncoordinated and confused:

• The initial lifeguard (Lifeguard W) to respond to the incident panicked after she pulled Colin from the water as she sat on the edge of the deck and rocked Colin in her arms while blowing her whistle.
• Lifeguard W did not immediately commence CPR, and vital seconds were lost as Lifeguard M ran to the scene, tripped on the pool deck on his way, and CPR was delayed until he got to Colin.
• Lifeguard CE retrieved either a broken AED or a Trainer AED, and another lifeguard had to go and retrieve another AED.
• There is speculation that when Fire and EMS arrived on the scene, the gate had not yet been opened and a pathway to the patient had not yet been created from the gate to the incident scene.
• SEC, the Assistant Aquatics Department Head and Lifeguard Supervisor, was not on the deck when the incident transpired and once he arrived on deck during this incident, it is unclear what role he played in the entire rescue operation.

As part of the emergency response drills that should be conducted, lifeguard supervisors need to take “command” of the incident and develop Incident Action Plans (IAPs), based on the circumstances of the incident and the resources required to manage the incident. This “Incident Commander” then needs to collaborate and share information with the Fire, Rescue, or EMS Incident Commander and/or crews upon arrival on the scene.

Someone, whether it was SEC or some other lifeguard, should have been in charge of the incident scene to be sure that 911 was called immediately; that appropriate and effective CPR was being administered; that an AED was available; that someone was outside the gate to flag down the responding Fire EMS units; that the gate was unlocked and a safe path created to the incident scene; that a backboard was brought to the scene and the child immobilized on that backboard.

We do know that lifeguards were involved in crowd control, but as to the management of the entire incident scene, it was entirely uncoordinated, which again, is a reflection of the lack of training and preparation of the lifeguard team as well as a reflection on the operation of the LTF Aquatics Department and LTF Corporate.

Nowhere in any of the materials developed and presented by LTF Corporate is there any training or information pertaining to the role that supervisors must play in incident coordination and command.

33. Failure of LTF Corporate to require or LTF Austin to complete a Rescue Report.

Although LTF Corporate has a policy that states, “a Rescue Report is completed when a lifeguard must aid someone in the water. An incident report must be completed in addition to this form. This form is used by the guard performing the rescue and is turned into the Aquatics Department Head”. A rescue report was not completed by any lifeguard in connection with Colin’s submersion incident. In fact, Erin Slade never saw, nor did she request a copy of this report, nor did she require this report to be completed. Nor was such a report produced in this case. Not only did Slade not require a report to be filled out, at the direction of LTF Austin management, she intentionally refrained from learning from other employees about the details of Colin’s submersion incident or attempted rescue.

Alicia Kockler of LTF Corporate never requested or required a copy of the report to be provided in connection with Colin’s submersion incident and attempted rescue.

The completion and review of the Rescue Report should be part of the critique of the incident in order to determine how appropriate the management of the incident was. But, again, upon Erin Slade’s return from vacation within days of the incident, there was no investigation by her, whatsoever, into the circumstances or management of this incident. This intentional non-investigation by the Aquatics Department Head, which was directed by LTF Austin management, raises serious concerns about LTF Austin and LTF Corporate’s ability to properly evaluate the circumstances and management of this incident and prevent similar incidents from occurring in the future at this and other Life Time facilities.

34. Failure of LTF Austin lifeguards to use appropriate whistle signals.

Upon recognition of Colin’s distress, Lifeguard W stood up in here chair and blew one short whistle blast. The LTF Corporate protocol, prior to her evacuating the chair to effect the rescue should have been to blow 1 long blast in order to alert the other guards that she was entering the water and that they should clear the pool. After rescuing Colin, she then sat on the deck with him in her arms and continuously blew her whistle.

This again is indicative of LTF Austin’s failure to train and drill the lifeguards in their recognition and response to emergency incidents.

SUMMARY

Based on the review of the materials provided by LTF Corporate, as well as a review of the operational structure of the LTF Austin Aquatics Department, it appears evident that the Public Safety operational aspects of this facility were indeed sorely lacking. Zones of Responsibility, which are critical to effective lifeguarding, particularly at facilities like this that attract young children, were not clearly identified. Lifeguard personnel were not appropriately trained. Although they may have been “certified”, they certainly could not be considered as “qualified”.

Life Time Fitness was, or should have been, fully aware of the LTF Austin operations. Alicia Kockler stated numerous times throughout her deposition that she had complete faith and trust in Erin Slade’s ability to direct and manage the Aquatics Department at the LTF Austin facility. Kockler was present for the Grand Opening of this facility and had a first hand opportunity to observe the operations at this facility.

Yet, none of the lifeguards deposed (or the Aquatics Department Head from LTF Austin) could agree upon the facility’s Zones of Responsibility. And there were no markings or other physical structures to objectively delineate these zones. LTF Corporate had identified the specific zones, as well as the placement of lifeguard stations. Yet, LTF Austin ignored these standards and placed lifeguard stations in inappropriate and ineffective locations.

Although LTF Corporate laid out a Lifeguard In-service training plan that was designed to re-certify lifeguard personnel on an annual basis by their participation in a one hour per month training program, the State of Texas required 4-hours of in-service training per month. Regardless, LTF Austin failed to document either the training, or those lifeguards who were in attendance. Furthermore, the training described within the In-Service Plan should have been presented as a pre-service training program, in order to qualify the lifeguards, prior to them assuming Public Safety and Surveillance responsibilities.

LTF Corporate developed Best Practice standards for lifeguard placement, lifeguard training, lifeguard supervision, emergency operations, whistle signals, etc. They also developed a reporting system that was supposed to document water rescue incidents, as part of their “Risk Management Program” for the purpose of analyzing incidents and assessing the response to these incidents. Yet, they didn’t require that these reports be sent back to Corporate. The police incident report states that Brian Singer with Life Time Fitness Corporate assured the detective that everyone at Life Time Fitness had also been asked that question (if anything could have been done differently to have saved Colin). Yet, Life Time Fitness failed to have the lifeguards complete a Rescue Report on this matter, and this incident was not discussed with Erin Slade, the Aquatics Department Head. Nor, did she make any effort to investigate this matter on her own based pm a conscious decision to remain ignorant of the details of what had happened.

LTF Corporate provided AEDs to the LTF Austin facility, but there was no thought process to place an AED within the Aquatics Department. In fact, the Aquatic Department Head’s request for an AED to be placed within the Aquatics Department was rejected by LT Austin management. Lifeguards were not appropriately trained in the location and use of the LTF Austin AEDs. These AEDs were not appropriately maintained, and when an AED was needed most, either a Training AED or a broken AED was brought to the incident scene, rather than an operational AED.

Life Time Fitness states that “effective January 2004 Life Time Fitness recognizes the American Red Cross Training Program as the standard of care for the Aquatics Department.” Yet, Life Time Fitness failed to recognize or use the Lifeguard Management curriculum developed by the American Red Cross. And, even though the American Red Cross advocates that Lifeguards be trained and equipped in the use of Bag-Valve-Mask Resuscitators, oxygen administration, and AEDs, there were no BVMs, nor was there any airway management and oxygen administration equipment available.

During the Family Swim on June 13, 2008, while the lifeguard-to-patron ratio advocated by Life Time Fitness should have required 6 lifeguards to be providing Public Safety and Surveillance to the patrons in the pool, along with a Lifeguard Supervisor on deck, there were only 5 lifeguards providing Public Safety and Surveillance, of which 1 of those lifeguards was responsible for the Kiddy Slide, and 2 others were responsible for the dispatch and exit of the 2-story water slides. And, the required Lifeguard Supervisor was inside the building, and not providing the direction, guidance, and supervision required.

Life Time Fitness advocates adherence to the 10/20 Rule as well as the 5-Minute Rule. Yet, Colin’s distress went unrecognized by “certified” lifeguard personnel for a time in excess of 7 minutes which is inexcusable and indicative of a complete failure to exercise reasonable care in performing patron surveillance.

Once Colin’s distress was recognized, the lifeguards at LTF Austin failed to manage the incident appropriately. There was no coordinated rescue effort and no one assumed Incident Command of the incident. Lifeguard Wills hesitated to enter the water; she relied on a patron to check on Colin and assist in removing him from the pool. And, once she finally removed Colin, she then panicked. She failed to alert the other lifeguards prior to evacuating her chair to effect the rescue. Once she grabbed Colin, she sat on the pool deck with Colin in her arms, and rocked him while blowing her whistle. Although there was an established Emergency Action Plan, this plan was not implemented. Lifeguard Morton ran to the scene, tripping and falling on the way. Other lifeguards scrambled to do various things to support this incident scene, but there was absolutely no coordination of effort. It was also implied that when Fire and EMS units responded, there was no one at the gate to flag them down; the gate wasn’t yet opened; and a pathway had not been created between the gate and the incident scene.

Although there was a trained paramedic on the scene, along with a nurse, both of whom assisted with the resuscitation effort, without the appropriate equipment, their efforts weren’t anymore effective than anyone else trained in basic CPR procedures. Neither a Bag-Valve-Mask Resuscitator, a Manual Hand-Held Suction Device, Oxygen Administration Equipment, Oropharyngeal Airways, or even Cervical Collars were available. The cost of this equipment is minimal. A Bag-Valve-Mask Resuscitator costs approximately $35.00. A Manual Hand-Held Suction Device costs approximately $60.00. A complete set of various sized Oropharyngeal Airways costs approximately $8.00. Cervical extrication collars cost ap