October 1, 2016 Estate of William Beals vs. the State of Michigan

William T. Beals was a 19-year-old, 5’7” teenager who was mildly autistic with Aspberger Syndrome. On May 19, 2009, William suffered a fatal submersion while using the Michigan Career and Technical Institute (MCTI) swimming pool during recreational swim.

Author: Gerald M. Dworkin
Date: November 17, 2011

William T. Beals was a 19-year-old, 5’7” teenager who was mildly autistic with Aspberger Syndrome. On May 19, 2009, William suffered a fatal submersion while using the Michigan Career and Technical Institute (MCTI) swimming pool during recreational swim.

William was a student at MCTI. He was one of approximately 24 MCTI students using the swimming pool. At the time of the incident, the pool was being supervised by only one lifeguard – William Harman. I have not yet determined whether there were other supervisors present in or around the swimming pool at the time of the incident.

According to the security tape footage, William Beals was standing in approximately 4’ of water when he surface dived and then swam underwater toward the deep end. However, he never re-surfaced. Lifeguard Harman is observed engaged in activities that intruded upon and/or distracted him from his primary responsibilities – public safety and patron surveillance. During the 18-minute tape that preceded the discovery of William on the pool bottom, Lifeguard Harman is seen walking or sitting along the pool edge. Not once within this time period was Lifeguard Harman observed to be sitting in the elevated lifeguard stand located along the side of the swimming pool. Just prior to the discovery of William on the bottom of the pool, Lifeguard Harman is observed on the deck of the shallow end of the swimming pool with a basketball in hand.

Prior to William being discovered, Matt Brinningstaull was in the deep end of the swimming pool. He had been diving for change on the pool bottom and was wearing goggles. He observed William “on the bottom of the floor on his side.” William was unresponsive on the bottom of the 10’ deep end of the pool.

Lifeguard Harman was standing on the deck in the shallow end of the pool when he was alerted to the emergency. He then ran to the deep end of the pool and jumped in to assist in extricating William from the water. Once William was removed from the pool, Lifeguard Harman exited the pool and began to assess William’s condition.

Bradley Bond-Michael had been swimming in the pool. He assisted Lifeguard Harmon in extricating William from the pool. He then went to find other staff members. He “went to the leisure office – no one was in there, went to dorm office then seen Ted and everybody running through the gym.”

Lifeguard Harman assessed William to be in respiratory and cardiac arrest. Harman then instructed others to get help and to call 911. According to the security tape footage, Lifeguard Harman is then seen leaving Beals on the pool deck to retrieve something and he then returns to Beals and initiates CPR.

Aaron Hayne had been at the pool. He observed Lifeguard Harmon pull William out of the pool. Because he was trained in CPR, he performed rescue breaths while Lifeguard Harmon performed chest compressions.

According to the Island City Area EMS/Delton Area EMS, upon their arrival CPR was being performed by ATF PLFD. Patient was cyanotic and lung sounds were described as rales. AED was attached but no shock advised. Patient was in asystole throughout care to arrival at hospital with CPR in progress. Positive pressure ventilation via bag-valve-mask was administered with oxygen at 15 lpm. Advanced airway and advanced cardiac life support care was administered on the scene prior to transport and maintained en-route to hospital.

William was transported to Borgess – Pipp Health Center in Plainwell, MI. He arrived at the hospital at 9:39 PM and was pronounced deceased at 9:45 PM in the emergency department by Dr. Jose Fuentes.

The autopsy findings stated the cause of death was drowning and the manner of death as accidental and indicated “congested and edematous lungs with abundant frothy edema fluid in the airways.” This indicates that William Beals did not experience a sudden cardiac arrest and that he progressed through the drowning process as his distress went unrecognized. It is also important to note that “autopsy revealed no significant external injuries and no internal injuries of the head, neck, chest, abdomen or pelvis were identified.” According to Sparrow Forensic Pathology, the “information regarding the circumstances surrounding the death of William Beals is obtained from the medical examiner investigator report (Allegan County Medical Examiner’s Office), emergency medical services and emergency department medical records available for review, and police reports (Prairieville Township Police Department).”

According to Lifeguard Harmon, “there was a ball, I went to put it away. I went to the end of the pool and I heard someone say “someone is drowning”. I ran as fast as I could to the person and I tried to pull him out. A lot of people around the pool weren’t listening to me. I couldn’t get them to do anything I said. I had people – Aaron Haynes – trying to do CPR and I didn’t know if he was certified. I had to stop him so I could do CPR, so I could do my job. I appointed someone to call 911 but people weren’t able to do so because you have to dial 9, 911. People couldn’t figure out the phone. I had my walkie-talkie and wasn’t able to get anyone to respond. I started doing CPR. About 30 seconds after I started doing CPR Kyle arrived and relieved me from doing CPR. I went and got the AED machine.”

William’s family reported that he could swim, although he had no formal swim training. He had a reported history of autism/Asperger’s syndrome, but had no other reported medical conditions and took no medications. According to Teresa Beals (William’s mother), “he had no seizure history and was not taking any medications.”

Police Officers Thompson and Gentry reviewed the security tape footage and believe William submerged in the shallow end and never resurfaced until he was found in the 10’ deep end, approximately 17 minutes later. After reviewing the same security tape footage, I concur with their findings. According to the surveillance tape footage, Lifeguard Harman pulled William out of the pool at 8:31 PM and began administering CPR. Kyle Baker, Fire and Safety Officer and First Responder, arrived at the scene at 8:32 PM and took over from there. Ted Kirk from Dorm staff arrived at 8:34 PM, and Paramedics arrived at 8:35 PM.

Upon my review of the surveillance tape footage, Lifeguard Harman was never once in the elevated lifeguard stand. William is observed surface diving from the 4’ section of the pool. During the entire 17 minutes prior to his being recognized on the pool bottom, the lifeguard was engaged in activities that intruded upon and/or distracted him from providing appropriate and effective surveillance. William’s initial submersion was directly in front of the elevated lifeguard stand. And, his location on the bottom of the deep end of the pool was directly in front of where Lifeguard Harman had been standing and sitting for approximately 15 minutes.

The police officers who viewed the surveillance tape footage made the same observations: “Lifeguard William J. Harman only guard on duty is clearly observed to be sitting at pool sides edge only a few feet from where Beals is discovered at from the time Beals goes under till the time of 6:50. Lifeguard then moves from poolside location and walks towards the center of the pool and begins to play basketball with himself. Seventeen minutes and twenty eight seconds elapse before in pool rescuer Matthew Brinningstaull is seen under the diving board and he makes observation of a body at the bottom of the pool.”

It is important to note that although the AED indicated no shock advised, “there was some discussion in improper placement of the AED pads either by the lifeguard Harman or Baker himself, as EMS and Paramedic advised upon arrival that AED left pad was improperly placed per EMS.” However, considering the fact that William’s distress went unrecognized for over 17 minutes and that he was submerged throughout this time, it is unlikely that William would have had a shockable rhythm at the time he was removed from the water.

BREACHES IN THE STANDARD OF CARE

Based on the previous discussions and my review of the materials listed in this report, it is my opinion that the Michigan Career and Technical Institute (MCTI) and its employees breached the Standard of Care that resulted in the drowning death of William T. Beals on May 19, 2009.

These breaches are listed as follows:

• Failure to provide adequate and effective patron surveillance during recreational swim activities

• Failure to provide qualified lifeguard personnel

• Failure to require the lifeguard to position himself in the elevated lifeguard stand

• Failure to establish appropriate and effective surveillance protocols

• Failure to establish and implement Standard Operating Procedures (SOPs) to govern the actions of lifeguard personnel

• Failure to rehearse and drill lifeguard personnel and program participants in appropriate Emergency Action Plans (EAPs)

• Failure to rehearse and drill lifeguard and staff in Emergency Response Plans (ERPs) for the response to medical emergencies within the pool area

• Failure to conduct a Threat Assessment to identify hazards and risks within the swimming pool area

• Failure to safeguard or prohibit activities that place patrons at heightened risk

• Failure to assess the emergency communications system

• Failure to provide appropriate directions for the use of the emergency telephone within the swimming pool area

• Failure to develop a comprehensive Risk Management Program to identify the hazards and risks associated with the use of the MCTI swimming pool

• Failure to plan for this incident; failure to train for this incident; and failure to appropriate the resources required to safely and effectively manage this incident

• Failure to establish Facility-Use Guidelines requiring supervision and accountability of students by other staff members

In summary, this was an incident that could have been and should have been easily prevented. Had the lifeguard been required to position himself in the elevated lifeguard stand, William’s distress could have and would have been easily recognized in a timely fashion, and intervention could have occurred prior to the onset of cardiac arrest.

The facility had an AED and trained personnel certified to administer CPR and use an AED. Had William been rescued in a timely manner, even after the onset of cardiac arrest, the window of opportunity would have still existed for a successful outcome with early CPR, early defibrillation, and early Advanced Cardiac Life Support.

Instead, the lifeguard was allowed to randomly walk around the edge the pool and was allowed to engage in activities that intruded upon and/or distracted him from his public safety and surveillance responsibilities.

And, although the participants in the pool were all students, there should also have been additional supervision and accountability provided by other staff members, such as other teachers or counselors.

Once the incident was finally recognized, the lifeguard was unable to communicate the emergency to others as the phone was not operable, according to the directions posted, and the radio was not operable.

This was a very tragic incident that never should have occurred. MCTI had a duty to safeguard William while he was engaged in aquatic recreation activities within the MCTI swimming pool. MCTI breached that duty resulting in the prolonged, unrecognized, and fatal submersion of William T. Beals on May 19, 2009.