Hansen vs. Half Moon Beach

6-year-old Dakota Lee Hansen experienced an unrecognized submersion incident on August 09, 2008 and died as a result of this incident. The actions or inactions of the owners, managers, operators, and lifeguard personnel either caused or contributed to her death. Based on my review of the materials previously identified, as well as my personal site visit, it is my opinion that there were numerous breaches in the standard of care. As a result, they failed to prevent this incident. They failed to recognize the incident, as well as its potential. And, they failed to effectively manage the incident, as well as its potential.

Author: Gerald M. Dworkin
Date: April 27, 2011

DESCRIPTION OF THE INCIDENT

Half Moon Beach Park is an outdoor recreation facility providing amusement and recreation services including a pay-for-use swimming facility. Skyline Paintball, Inc., together with the other co-defendants, owns, co-owns, leases and/or co-operates Half Moon Beach Park. Strasburg Land, L.L.C. and Dunmore Land, L.L.C. leased the property known as Half Moon Beach Park to Skyline Paintball, Inc. and Half Moon Beach Park, Inc.

On August 9, 2008, the Hansen family, consisting of Keith Hansen (father), Wendy Hansen (mother), 15-year-old Shannon Hansen, Joey Hansen, 6-year-old Dakota Lee Hansen, and 2-year-old Joshua Hansen, as well as a foster child, Cameron O’Sullivan, traveled to Half Moon Beach Park. They went to the park along with the family of Kim and Sean McGarry and the family of Joe and Robin Martinaz. The Hansen family had never been to Half Moon Beach Park prior to this date. They had heard about the park from a member of their church.

Upon their arrival at approximately 12:30 PM, they purchased tickets from Skyline Paintball, Inc. for admission to Half Moon Beach Park. Dakota was issued a wristband, numbered 14579, by Skyline Paintball. The weather was sunny and clear with an air temperature of approximately 80 degrees.

Wendy Hansen and Kim McGarry were sitting at the edge of the water watching their children who were playing in the water. Joshua Hansen was seated behind Wendy playing with sand toys. Shannon was in the adult section of the Half Moon Beach Park near the barge with the three older McGarry chlldren. Sean McGarry was seated behind and near Wendy Hansen and was holding Chad McGarry and letting Chad play in the sand.

There was a lifeguard stand immediately behind Wendy Hansen. However, a female lifeguard was observed to be sitting on the sand, near the chair, rather than sitting in the elevated lifeguard stand.

Dakota played in the water for approximately 30 – 45 minutes during which time Wendy Hansen and Kim McGarry stayed at the water’s edge watching the children. While within the non-swimmer roped off area, the children were able to stand up at waist deep level everywhere within that area.

Dakota was able to progress beyond the rope marking the boundary of the non-swimmer area and then immediately progressed into water over her head due to the bottom configuration of the quarry. Her progression into deep water was unobserved by lifeguard personnel. Once in water over her head, she became distressed and drowned without her distress being recognized by lifeguard personnel. No lifeguard was observed sitting in the elevated lifeguard stand immediately prior to or during the onset of Dakota’s submersion incident.

According to an interview with Vincent Ferraiuolo, he had seen Dakota in the water. She had been splashing around, “kind of like she was drowning.” He had observed her bobbing in the water, but thought she was playing. He had also observed a male lifeguard on the pier in close proximity to Dakota during this time.

An 11-year-old child, Daisy Brosious, who was also in the non-swimmer area, observed Dakota floating motionless beyond the lifeline. She then alerted the lifeguards that a child may have drowned or was in difficulty. Wendy Hansen, Kim, and Sean McGarry saw the lifeguards going into the water with boards and saw them come out with Dakota. An adult female initiated CPR on Dakota. A male lifeguard then took over from her. A call to 911 was placed which resulted in Police, Fire, and EMS response to Half Moon Beach Park.

Corporal Travis Eugene Cave and Officer Derrick Nicely of the Strasburg Police Department responded to the drowning call, as did the Middletown Rescue Squad and the Strasburg Volunteer Rescue Squad. According to the EMS Report, a 6-year-old child had been found floating face-down in approximately 6′ of water. She was unconscious and unresponsive. Upon their arrival, CPR was in progress. ACLS protocols were established; however, they were unable to intubate her prior to her arrival at the hospital.

Dakota was transported by ambulance to the Winchester Medical Center Emergency Hospital. Upon arrival, Dakota was assessed to be pulseless and apneic with CPR and positive pressure ventilation in progress. Her pupils were fixed and dilated. There were no cardiac sounds and no peripheral pulses. Her lungs were diminished with assisted ventilation.

Dakota was intubated at the hospital. Her lungs were suctioned of large amounts of fluid but she was very difficult to ventilate due to high pressure presumably from aspiration of water. The code was continued and ACLS protocols were administered in the hospital for approximately 20 minutes in addition to the 30 minutes prior to her arrival, but the cardiac monitor still showed cardiac asystole. 6-year-old Dakota Lee Hansen was declared deceased at 14:44 hrs. She died as a result of an unrecognized submersion incident at Half Moon Beach Park.

Of interest to note is the fact that several weeks prior to Dakota’s drowning, another person had also drowned at the same facility. Yet, there were no measures taken on the part of the owners, managers, operators or lifeguard personnel to evaluate and improve the lifeguard operations at the park prior to Dakota’s submersion incident.

Lifeguards present at the time of the incident were:

• Brooke Hall
• Jesse Dove
• Ryan Cress
• Jonathan Weitman

Co-manager, Jessica Cutlip, was also thought to be at the facility prior to and during this incident.

Numerous comments from witnesses about the inadequate lifeguard operations at Half Moon Beach Park included:

• The lifeguards were not in the elevated lifeguard stands;
• The lifeguards were seen text messaging on their phones;
• The lifeguards were observed huddled together on the beach;
• There was no supervision of the lifeguards;
• There were 100+ people at the park.

Also, at the time of the incident, witnesses believe there were three lifeguards around the tower and two near the lunch counter at the time of the incident.

STRASBURG POLICE DEPARTMENT’S HALF MOON BEACH SAFETY EVALUATION

Half Moon Beach closed for the season after Dakota’s submersion incident. The Strasburg Police, Rescue and Fire Departments, and a Virginia State Police Dive Team completed a safety evaluation of the park facility.

The safety report recommended that the Park have at least three staffed lifeguard stations, and that all lifeguards receive site-specific training. At the time of both drownings, only one lifeguard station was in use.

According to Strasburg Police Chief Tim Sutherly (nvdaily.com May 23, 2009), “the beach’s operators were “very receptive” to the recommendations made in the report.” Sutherly said the operators assured him “they would definitely look into some of those things” if they reopened, but the last he heard was that “they weren’t going to reopen.”

The following is a summary of the Police Department’s evaluation report:

• There is afternoon sun glare making visibility difficult and that there are line-of-sight obstacles.
• Lifeguards are rotated every 15 minutes. (The report does not state what/where the designated lifeguard stations are).
• There should be three (3) staffed elevated lifeguard stations, rather than the one (1) that was present on the day of the incident.
• The boat docks should be moved away from the non-swimmer area. (The report does not address who needs to manage/operate the boat rental/boat docks.)
• Have at least two AEDs available. (There were no AEDs at the time of the incident.)
• Remove the backboard from the first aid station and place it at the elevated lifeguard stand.
• All lifeguards should have a rescue tube in their possession while on duty.
• Two-way radios and whistles should be used, instead of cell phones, for communication.
• Lifeguards should be provided site-specific pre-service and continuous in-service training to qualify them for open water operations.
• Lifeguard supervisors should be appropriately trained and certified in CPR, AED, and Lifeguarding.
• Written Emergency Response Plans should be developed and lifeguard drills should be conducted to rehearse these ERPs.

VIRGINIA STATE POLICE DIVE REPORT

At the request of the Strasburg Police Department Chief Tim Sutherly, the Virginia State Police Search and Recovery Team was requested to dive the Half Moon Beach Quarry and to investigate any anomalies that may have caused or contributed to Dakota’s submersion incident, as well as the earlier drowning incident. The inspection was conducted on August 12, 2008, beginning at 09:00 hrs.

According to the report, the team utilized a dual-man compass run that allowed the divers to grid off the swimming area, making note of depth, abrupt depth changes, temperature changes, venting, wildlife risk, and any other irregularity of the quarry.

According to their report, there were no irregularities of any form. Depths ranged from zero depth to 30′. Temperatures ranged from 68 degrees at the surface, down to 55 degrees. The thermacline was encountered at about 18′ with an abrupt drop in temperature.

The bottom of the quarry was relatively clean and clear of any obstructions or trappings. There was no noticeable current and no dangerous wildlife was encountered. Bottom sea grass was observed, but was not considered to be a hazard.

The inspection report shows that the depths within the non-swimmer area range from 1′ to 2′, up to and adjacent to the lifeline that diagonally marks this area. However, the depths drastically change and increase to between 4′ and 8′ beyond the lifeline. The area where Dakota was found was in the 8′ depth range.

BREACHES IN THE STANDARD OF CARE

6-year-old Dakota Lee Hansen experienced an unrecognized submersion incident on August 09, 2008 and died as a result of this incident. The actions or inactions of the owners, managers, operators, and lifeguard personnel either caused or contributed to her death. Based on my review of the materials previously identified, as well as my personal site visit, it is my opinion that there were numerous breaches in the standard of care. As a result, they failed to prevent this incident. They failed to recognize the incident, as well as its potential. And, they failed to effectively manage the incident, as well as its potential.

The owners, managers, operators, and lifeguards of Half Moon Beach:

1. Failed to assess the number of patrons using the facility and failed to strategically position lifeguard personnel to safeguard the public engaged in aquatic recreation activities within the non-swimmer and swimmer areas of the park.

2. Failed to recognize that weak or non-swimmers are at heightened risk of they are allowed to progress beyond the non-swimmer area of the park.

3. Failed to recognize that a lapse in supervision is to be expected by parents who are supervising more than one child at a time and they failed to implement appropriate and additional layers of protection to safeguard young children engaged in aquatic recreation activities within the non-swimmer and swimmer areas of the park.

4. Failed to recognize that young children are attracted to water and have little concept of the dangers associated with water, and that the actions of young children around the water is unpredictable.

5. Failed to realize that drowning is a silent death and that drowning victims do not call out and wave for help and that lifeguard personnel need to be strategically positioned and vigilant in their duties.

6. Failed to recognize Dakota progressing into deeper water that was beyond her capabilities, and failed to recognize signs of distress as displayed by Dakota prior to and during the drowning process.

7. Failed to intervene and provide rescue before the onset of respiratory and cardiac arrest.

8. Failed to assess the public safety needs required by the physical nature of this facility and failed to establish appropriate lifeguard stations needed to provide effective patron surveillance and rescue.

9. Failed to identify physical hazards that existed at this facility, and they failed to remove, correct, or warn patrons of these hazards.

10. Failed to identify those activities that place patrons at heightened risk and failed to either safeguard or prohibit those activities.

11. Failed to provide vigilant and effective patron surveillance and supervision by competent and qualified lifeguard personnel.

12. Failed to provide state-of-the-art safety and rescue equipment to include:
a. Personal Resuscitation Masks
b. Bag-Valve-Mask Resuscitator
c. Elevated Lifeguard Stands
d. Manual Hand-Held Suction Devices
e. Automated External Defibrillators
f. Oxygen Administration Equipment
g. Radio Communications
h. Plastic Backboard with Effective Strapping System & Head Immobilizer
i. Rescue Buoys for Each Lifeguard

13. Failed to prohibit lifeguards from engaging in activities that intruded upon their patron surveillance, safety and rescue responsibilities.

14. Failed to prohibit lifeguards from engaging in activities that distracted them from their patron surveillance, safety and rescue responsibilities.

15. Failed to appropriately train lifeguard personnel to recognize hazards and risks to prevent submersion incidents of young children.

16. Failed to educate the public about the hazards and risks, and they failed to establish rules and regulations and facility-use-guidelines for parents to safely and effectively supervise young children engaged in aquatic recreation activities in the non-swimmer and swimmer sections of the facility.

17. Failed to implement appropriate Layers of Protection to safeguard young children engaged in aquatic recreation activities in the non-swimmer and swimmer sections of the facility.

18. Failed to prohibit weak and/or non-swimmers from progressing out to and beyond the lifeline separating the non-swimmer from the swimmer sections of the facility.

19. Failed to establish appropriate and effective surveillance protocols to be used by lifeguard personnel to safeguard patrons engaged in aquatic recreation activities in the non-swimmer and swimmer sections of the facility.

20. Failed to train lifeguards in appropriate and effective surveillance protocols to be used to safeguard patrons engaged in aquatic recreation activities in the non-swimmer and swimmer sections of the facility.

21. Failed to assess the lifeguards’ ability to appropriately and effectively safeguard patrons engaged in aquatic recreation activities in the non-swimmer and swimmer sections of the facility.

22. Failed to establish Zones of Responsibility for lifeguard personnel.

23. Failed to provide and/or require lifeguards to have and use polarized sunglasses.

24. Failed to require lifeguard personnel to use the elevated lifeguard stand.

25. Failed to provide or require lifeguard personnel to be trained and certified at the Waterfront Lifeguarding certification level.

26. Failed to provide site-specific pre-service training to qualify lifeguard personnel.

27. Failed to provide continuous in-service training of lifeguard personnel.

28. Failed to establish Standard Operating Procedures (SOPs) dealing with all operational responsibilities of lifeguard personnel.

29. Failed to develop and implement Emergency Action Plans (EAPs) and to conduct simulated emergency drills to prepare lifeguard personnel for their response to actual emergencies.

30. Failed to develop and implement Emergency Response Plans (ERPs) and to conduct simulated emergency drills to prepare lifeguard personnel for their response to actual emergencies.

31. Failed to conduct emergency drills and to assess lifeguard personnel in their ability to safely, effectively, and rapidly respond to emergency incidents and to develop and appropriate and effective Incident Command structure.

32. Failed to require the use of Personal Flotation Devices (PFDs) by weak or non-swimmers engaged in aquatic recreation activities within the swimmer section of the facility.

33. Failed to require adult supervision within arm’s reach of weak or non-swimmers engaged in aquatic recreation activities within the swimmer section of the facility.

34. Failed to require supervisors to be trained in lifeguarding and/or CPR/AED for the Professional Rescuer level.

35. Failure to provide and require lifeguard personnel to carry a Personal Resuscitation Mask on their person at all times.

36. Failure to provide and place appropriately-sized Bag-Valve-Mask Resuscitators strategically around the park for use in response to respiratory and/or cardiac emergencies.

37. Failure to provide and place manual hand-held suction devices strategically around the park for use in response to respiratory and/or cardiac emergencies.

38. Failure to provide and place oxygen administration equipment strategically around the park for use in response to respiratory and/or cardiac emergencies.

39. Failure to provide and place Automated External Defibrillators (AEDs) strategically around the park for use in response to cardiac emergencies.

40. Failure to conduct an audit of the park to determine the hazards and risks, as well as to evaluate the operational structure and capability of the lifeguards.

41. Failure to provide qualified and certified lifeguard personnel.

SUMMARY

At the time this incident occurred, there were at least four (4) lifeguards on duty, and the assumption is that at least one (1) supervisor was on duty as well. The span of the swimming area was approximately 130′ across, with only 1 elevated lifeguard stand established on the beach. There were 100 or more patrons using the park at the time, and there were no lifeguard personnel positioned in the elevated stand nor were there lifeguard personnel strategically positioned throughout the park.

It is unclear what the training and certification was of the lifeguard personnel, but based on the operational protocols that were in place at the time of the incident, it is evident they were not appropriately trained and certified in Lifeguarding, Waterfront Lifeguarding, and CPR/AED for the Professional Rescuer. It is also clearly evident that the operational protocols were lacking or non-existent, and that appropriate site-specific training was lacking or non-existent.

The American Red Cross provides several lifeguard training curriculums, including Lifeguard Training, Waterfront Lifeguard Training, and Lifeguard Management. The report generated by the Strasburg Police Chief, implies that the supervisors were not appropriately trained and certified. And, based on the actions of the lifeguards prior to and during this incident, it seems apparent that the lifeguards were not trained in Waterfront Lifeguarding. And, even if the lifeguards were trained in CPR/AED for the Professional Rescuer, the lifeguards were not provided a Bag-Valve-Mask Resuscitator or an AED, both of which are included as part of the CPR/AED for the Professional Rescuer curriculum. And, a Personal Resuscitation Mask was not immediately available for use as soon as Dakota was removed from the water.

On or about July 16, 2008, 26-year-old Nathaniel Braxton King of Marshall, Virginia, drowned at Half Moon Beach Park. This situation, in and of itself, should have put the owners, managers, operators, and lifeguards on notice of the hazards and risks associated with this facility. And, they should have immediately evaluated their operational protocols, equipment, training, staffing, etc. in order to prevent another tragic incident. Yet, several weeks after the July 15 incident, the lifeguards continued to operate in the same haphazard method as they had previously. As a result, they failed to prevent Dakota’s submersion; they failed to recognize the potential for this incident; they failed to recognize the incident itself; and they failed to appropriately and effectively manage the incident.

There were no warnings intelligible to a 6-year-old child of the steep drop-off near the area roped off for non-swimmers. And, there were no warnings provided Dakota’s parents about the hazards and risks associated with the design and operation of this facility. As indicated in the Virginia State Police Dive Report, “the depths drastically change and increase to between 4′ and 8′ beyond the lifeline.” The area where Dakota was found was in the 8′ depth range. The public, namely Wendy Sue Hansen, should have been appropriately warned of the drastic depth changes in close proximity to the shallow area. And, the lifeguards should have been fully aware of these hazards and should have cautioned Mrs. Hansen or removed Dakota from that area, prior to her becoming distressed.

When Dakota was playing near the rope at the boundary, she stepped off of the ledge into very deep water and was unable to recover and swim to shore. Had vigilant, strategically positioned, and appropriately trained lifeguards been on duty, they would have and should have prevented her from progressing to the deeper water with such a severe drop-off. And, they would have and should have recognized Dakota’s distress long before she deteriorated into respiratory and then cardiac arrest. In fact, it took an untrained child to recognize Dakota’s distress and alert the lifeguards to the emergency.

Several witnesses have addressed the inattentive actions of the lifeguards, including distractive actions, such as talking to one another, text messaging, using cell phones, etc. There is also a report of one of the lifeguards engaged in activities that intruded upon his public safety responsibilities, namely operating the boat rental concession, even though he was only a short distance from Dakota as she struggled in the water and then deteriorated into respiratory and cardiac arrest.

Although the lifeguards should have been trained in CPR/AED for the Professional Rescuer, they did not have the appropriate resuscitation equipment required to safely and effectively respond to her medical condition, namely respiratory and cardiac arrest, upon her removal from the water. There was no Bag-Valve-Mask Resuscitator, the Personal Resuscitation Mask was delayed, and there was no Automated External Defibrillator (AED) available. Furthermore, because of the design and location of this facility, the lifeguards should have been trained in Oxygen Administration, and should have had oxygen administration equipment available to effectively respond to a patient in respiratory and cardiac arrest.

In summary, this incident could have and should have been prevented. If Dakota’s swimming skills were not sufficient to be in the deep water section of the facility, the lifeguards should have determined this and should have prohibited her from entering the deep water area.

The incident and/or its potential should have been recognized quickly so that appropriate interventions could have been implemented. Unless Dakota experienced some medical condition that caused her to experience sudden cardiac arrest, which is unlikely considering her age, then Dakota would have struggled prior to her deterioration into respiratory and cardiac arrest. Yet, because of the lack of surveillance protocols and operational procedures, Dakota’s distress went undetected by lifeguard personnel. In fact, it was a young child who observed Dakota lying motionless at the water’s surface, and not a trained lifeguard who made that observation.

Finally, this incident was absolutely mismanaged. The only effective way to treat a hypoxic patient resulting from a submersion incident is with aggressive CPR, including positive pressure ventilation with high-concentration delivery of oxygen delivered through the use of a bag-valve-mask (BVM) resuscitator, and defibrillation using an AED. However, neither the BVM, oxygen administration equipment, or the AED was available for use.

It is the opinion of this expert, this facility was operated in total disregard of accepted standards and practices, and as a result, the owners, managers, operators, and lifeguards at Half Moon Beach Park failed to prevent Dakota’s submersion incident; they failed to recognize the incident, as well as its potential; and they failed to appropriately and effectively manage the incident, as well as its potential.

Suit in Girl’s Death Settled

STRASBURG — A wrongful death suit in the drowning of a 6-year-old girl at Half Moon Beach three years ago has been settled for $1 million.

The Northern Virginia Daily,  June 16, 2011

Family of Dakota Lee Hansen, 6, to receive $1 million

By Sally Voth

An 11-year-old girl found Dakota Lee Hansen, of Culpeper, dead in 8 feet of water on Aug. 9, 2008, according to Shenandoah County Circuit Court documents. She was two weeks away from her 7th birthday.

Her father, Edward K. Hansen, filed a $24.35 million lawsuit against Half Moon Beach Park Inc., Skyline Paintball, Strasburg Land LLC, Dunmore Land, the estate of Leo Bernstein and Stanley W. Colton.

A settlement reached among the parties was approved by Circuit Judge Dennis L. Hupp on June 9, according to court documents. A jury trial had been scheduled for this past spring.

Colton and the Bernstein estate were dismissed as defendants in the complaint last month. Both men were on the board of directors of Half Moon Beach.

According to Hupp’s order, attorneys for the Hansens will get about $380,000, with the remainder being divided among Hansen and his wife, Wendy, and their seven surviving children, ranging in age from 2 to 31.

The award for the three youngest boys — Joseph, Joshua and Dylan — is going into a four-year education fund that they will start to receive at age 18, according to a report from guardian ad litem Jeremy McCleary.

According to the lawsuit, Half Moon Beach and Skyline Paintball co-owned and co-operated Half Moon Beach Park, which was leased to them by Strasburg Land and Dunmore Land.