Finding into death of Paul Daniel Rayudu
Deceased
Paul Daniel Rayudu
Demographics
22y, male
Date of death
2014-02-08
Finding date
2016-08-18
Cause of death
hypoxic ischaemic encephalopathy in the setting of immersion (drowning)
AI-generated summary
Paul, a 22-year-old with limited swimming experience, drowned at WaterMarc public pool on 2 February 2014 in a crowded busy period. The 50-metre pool was being divided by a movable boom, which two lifeguards were returning to the deep end, creating a sudden drop-off zone (1.5m depth change). During the boom movement, the pool's supervision was ineffective: one lifeguard was sent to conduct water testing, another was unclear about his supervisory responsibilities, and three lifeguards were distracted attempting to secure the boom in position. Paul and his girlfriend entered the water near the drop-off zone and both became submerged. Although patrons and staff performed prompt CPR, Paul suffered severe hypoxic-ischaemic brain injury and died 6 days later. The coroner found the death preventable. Key preventable factors included: inadequate dedicated supervision during the boom movement, failure to communicate clear supervisory responsibilities to lifeguards, and insufficient consideration of the risks posed by moving a boom while patrons remained in water, particularly near the hazardous drop-off zone.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- inadequate supervision of the 50-metre pool while the boom was being moved
- failure to designate a dedicated lifeguard to supervise the 50-metre pool during boom movement
- lifeguards distracted by difficulties in seating the boom due to misalignment requiring refloating
- lack of clear communication of supervisory responsibilities between Duty Manager De Pasquale and lifeguards
- decision to move the boom during busy operational hours with patrons still in the water
- Paul's location in vicinity of drop-off zone at time boom was moved
- sudden depth change created by boom movement placing Paul out of his depth
- Paul's limited swimming experience not disclosed to facility staff
- extremely busy pool conditions on hot summer day with approximately 300-700 patrons
- high turnover and young age of lifeguards (average 18.7 years)
- public announcement system not functioning, preventing safety warnings to patrons
Coroner's recommendations
- Belgravia Leisure implement a system (e.g. signage) requesting patrons to inform staff of vulnerabilities or non-swimming status before entering water
- Belgravia Leisure in consultation with Banyule City Council explore options for communicating with patrons with English language challenges regarding vulnerabilities (e.g. visual imagery at reception, multi-lingual materials)
- Secretary of Department of Premier and Cabinet work with Victorian government to establish a central oversight and regulation body for public swimming pool operation to ensure safety standards are applied and upheld consistently across industry
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