Drowning Incident at Alabama YMCA
Date: Date of Incident: February 14, 2003
On Friday, February 14, 2003, while the local schools were closed for a teacher’s in-service day, 5-year-old Lucas Shane Terry attended the YMCA of the Shoals “Vacation Day Camp”. There were 23 children in attendance at the Vacation Day Camp. Four of these children, including Lucas, were physically and mentally handicapped with special needs. Their ages ranged from 5 to 12 years of age. Approximately half of the children were weak or non-swimmers. The children were brought to the YMCA by two Childcare workers providing a childcare worker/child ratio in excess of 1:11. Two lifeguards were assigned to “guard” both the leisure pool as well as the lap swimming pool.
Lucas was observed by lifeguard personnel jumping into the pool and entering the deep water of the Leisure pool, even though he was a non-swimmer. Rather than sitting in an elevated lifeguard stand, one of the lifeguards was sitting in a lawn chair on the swimming pool deck, while the other lifeguard was standing on the pool deck. According to one lifeguard, Lucas was speaking with and touching the lifeguard’s leg. Rather than alert the Childcare workers to speak with or manage Lucas, the lifeguard got up and moved away from Lucas while he continued jumping in and out of deep water.
At some point, Lucas was observed unconscious and submerged below the water’s surface by another child who then alerted the lifeguards. The lifeguards removed Lucas and he was assessed to be cyanotic, unresponsive, and in respiratory and cardiac arrest. One of the lifeguards called the switchboard to inform them there was a drowning at the pool. CPR efforts were initiated and maintained until the arrival of EMS personnel.
The Fire Department was dispatched to the scene at 1:04 p.m. with a documented arrival time of 1:07 p.m. Upon their arrival, they observed CPR in progress by YMCA staff as well as a physician. However, no suction (airway management) and no oxygen administration equipment was in use at that time.
The EMS Ambulance was dispatched at 1:03 p.m. and arrived on scene at 1:09 p.m. Upon their arrival, they assessed Lucas to be unresponsive, cyanotic, and in cardiac arrest with fixed and dilated pupils. Advanced Life Support (ALS) protocols were administered, including an ET Tube, an IV line, and cardiac medications.
Lucas was transported to the Hospital with ALS protocols administered en-route and arrived at the hospital still in full cardiopulmonary arrest. At the hospital, Advanced Cardiac Life Support (ACLS) protocols were administered to no avail, and Lucas was pronounced dead at 2:42 p.m.
Lessons Learned
When Lucas was removed from the water, CPR was initiated and maintained until EMS arrived and took over patient care. Upon removal from the water, Lucas was assessed to be unresponsive, cyanotic, and in cardiac arrest. Upon arrival of EMS, they assessed Lucas to be unresponsive, cyanotic, and in cardiac arrest with fixed and dilated pupils. Based on these observations, it is estimated that Lucas” submersion went undetected by the lifeguards and Childcare workers for a minimum of 4 – 6 minutes before he was discovered by another child who then notified the lifeguards of Lucas’ distress. It is absolutely critical that lifeguard personnel be strategically positioned in elevated lifeguard stands and that childcare workers maintain effective supervision of their children to supplement and support the lifeguards’ supervision.
The swimming levels of children in organized groups should be assessed and unless they can pass a specific swim test, then the children should be confined to the shallow end of the swimming pool, or the child should be fitted with an approved Personal Flotation Device (PFD).
The deep end should be clearly defined with a lifeline and an underwater depth line. In addition, lifeguards should be assigned a specific zone of responsibility for surveillance and these zones should be clearly defined as well.
Children with special needs require additional supervision when in, on and around the water. Lifeguards and childcare workers should provide vigilant supervision, and additional supervision may be required depending upon the size and configuration of the pool or facility, as well as the activities the children are engaged in.
Lifeguard personnel should be qualified by their employer. Certification, by itself, only implies that the individual met all the educational requirements of their lifeguard training course by the course completion date. Only site-specific pre-service training, formal Standard Operating Procedures (SOPs) or Guidelines (SOGs), and Emergency Response Plans can qualify the lifeguard personnel.
An adequate number of lifeguards must be available at all times at “guarded” facilities. The number of lifeguards required is dependent upon the size, shape and configuration of the facility, the skill level and numbers of patrons in the water, the activities the patrons are engaged in, and the ability to adhere to the 30-second Rule, the 10/20 Rule, and/or the 10 x 10 Rule, or combination of those rules.
Emergency Action Plans (EAPs) and Emergency Response Plans (ERPs) must be in writing and lifeguard personnel must drill in the implementation and administration of these plans.
Aquatic facility managers must conduct an on-going threat analysis of the facility to determine and mitigate the physical hazards that may exist within the facility, and to prohibit or safeguard those activities that place patrons at increased risk.
“Guarded” facilities should be equipped with oxygen administration equipment (oxygen tank and regulator); airway management equipment (manual hand-held suction device and oropharyngeal airways); positive pressure ventilation equipment (personal resuscitation masks or shields and bag-valve-mask resuscitators) and Automated External Defibrillators (AEDs), and all lifeguard and other responding personnel must be trained in the use of this equipment.
Summary
Lucas drowned in the presence of 2 lifeguards and 2 Childcare workers. Had these personnel acted appropriately, the submersion and drowning death of Lucas Shane Terry would have and should have been easily prevented. The YMCA had a duty to prevent this incident. They had a duty to recognize the potential for this incident as well as the incident itself. And, they had a duty to manage, not only the incident, but the potential for this incident. Yet, the YMCA failed in each of these areas which resulted in the submersion and drowning death of Lucas on February 14, 2003.
Prior to and during Lucas’ drowning incident, both swimming pools (the Leisure Pool and the Lap Pool) were being supervised by only 2 Lifeguards. The Lap Pool should have had at least 1 lifeguard dedicated specifically to that facility, while the Leisure Pool should have had at least 3 lifeguards dedicated specifically to that facility.
By placing Lucas in the Leisure pool and not providing the supervision, the SOPs, the training, the equipment, etc., they abandoned him which resulted in his submersion and drowning death. In addition, one lifeguard even admits to purposely getting up and moving away from Lucas while he continued to jump in and out of the pool in water that was over his head. In doing so, this lifeguard abandoned Lucas as well as her lifeguard responsibilities.
Almost a year prior to this incident (March 28 – 29, 2002), a representative from Professional Aquatic Consultants International conducted an audit of the YMCA of the Shoals aquatic facility and found a number of deficiencies that were identified and discussed with representatives of this Y. Yet, the YMCA of the Shoals chose to disregard portions of this audit report and failed to implement portions of the recommendations made as a result of this audit.
Lifeguards Hennessee and Ballard failed to follow their training curriculum standards and procedures as identified within the On the Guard II: The YMCA Lifeguard Manual, (4th edition). The Aquatics Director, Fran Davis, failed to implement the standards and procedures identified within this same textbook, as well as the standards, procedures, and guidelines published in other YMCA or aquatic industry publications.
The YMCA of the Shoals had all the tools at their disposal to assist them in the development of the required Standard Operating Procedures, Emergency Action Plans, and Emergency Response Plans to safely operate and manage their aquatic facilities. However, instead, they chose to ignore these tools and to operate in an unsafe and dangerous manner.
Based on my review of the documents provided, including photographs of the Leisure pool, it is my opinion that the Leisure pool is an unsafe and very dangerously designed facility. Considering the shape, design, depth, features, etc. this facility certainly required more stringent safeguards and operational protocols in order to guarantee the safety of children engaged in recreational aquatic activities at this facility.
Finally, based on my review of all the documents previously identified, it is my opinion that the Childcare workers, Lifeguards, Aquatics Director, and management of the YMCA of the Shoals were derelict in their duties and responsibilities which resulted in the submersion and drowning death of Lucas Shane Terry on February 14, 2003.