Coronial
QLDother

Boyce, Amanda Helen

Deceased

Amanda Helen Boyce

Demographics

13y, female

Coroner

Rinaudo

Date of death

2001-12-14

Finding date

2006-12-18

Cause of death

Pneumonia, due to or as a consequence of Hypoxic Brain Damage, due to or as a consequence of Spa Accident

AI-generated summary

Amanda Helen Boyce, aged 13, drowned in a spa pool at a resort after her long hair became entrapped in the pump suction system. She was submerged for an estimated 10-20 minutes before being freed. Despite immediate CPR and resuscitation efforts by bystanders and paramedics, she suffered hypoxic brain damage and died four days later. The spa had multiple design and maintenance deficiencies: the pump installed in 2001 created suction velocities 35.6% higher than permitted by Australian Standard AS 2610.1, the suction point covers exceeded safe flow velocities by 469%, a diving goggle was trapped under a cover creating obstruction, and the outlet pipe was partially crushed. The coroner found the death was preventable had the facility complied with the Australian Standard through proper design controls, maintenance procedures, emergency equipment, and safety signage. Critical lessons include the importance of written maintenance agreements between facility operators and service providers, regular inspection protocols, and strict adherence to pool safety standards.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicineintensive carepaediatricsoccupational and environmental health

Error types

systemmaintenancedesign

Clinical conditions

drowninghypoxic brain damagecardiac arrestaspiration pneumonia

Procedures

mouth to mouth resuscitationexternal cardiac massageendotracheal intubationhelicopter evacuation

Contributing factors

  • Suction pipe flow velocities 35.6% higher than permitted by AS 2610.1
  • Flow velocities through suction point covers 469% higher than permitted by AS 2610.0
  • Excessive turbulent flow (Reynolds number increased by 29.8-104%)
  • Suction point cover not in accordance with standard
  • Outlet pipe partially crushed reducing water flow capacity
  • Diving goggle trapped under suction point cover causing obstruction
  • Absence of emergency spa pool pump stop and alarm
  • Lack of prominent safety signage regarding head submersion risk
  • No written maintenance agreement between facility and service provider
  • Inadequate supervision of spa pool maintenance responsibilities
  • Child's long hair not secured before water entry

Coroner's recommendations

  1. All public spa pools should comply with the relevant Australian Standard AS 2610.1. If they do not, they should be brought into compliance.
  2. As a minimum, public spa pool owners should control suction pipe flow velocity by fitting an orifice plate into the pump discharge pipe (estimated cost $200).
  3. Fit a pressure gauge to the pump suction connection to permit regular testing and verification that both branches of the suction pipe are unobstructed (estimated cost $100).
  4. Fit new suction point covers that comply with AS 2610.1 to reduce the risk of foreign body entrapment (estimated cost $100).
  5. Fit an emergency spa pool pump stop and associated alarm as required by AS 2610.1 (estimated cost $500).
  6. Owners must ensure that all spa pools have a prominent sign complying with AS 2610.1 clause 2.19.4, giving significant prominence to requirements that CHILDREN BE SUPERVISED IN THE SPA AREA and that USERS NEVER PUT HEAD UNDER WATER, with this rule in red lettering.
  7. Owners who have service agreements with professional pool cleaners must clearly set out in writing the responsibility of each party to ensure clarity of obligations and compliance with standards.
  8. The Health and Safety Alert – Public Spa Pools should be upgraded to incorporate these recommendations and published or republished.
Full text
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