Finding into death of Ze Cheng (Tony) Guan

Contributing factors

• lifeguards performing non-supervisory tasks during supervision periods
• lack of structured supervision protocol identifying responsible lifeguard for specific areas
• failure of three present staff members to notice the incident
• inadequate identification of patrons with medical conditions or disabilities

Coroner's recommendations

1. Non-supervisory tasks by lifeguards should be limited to only tasks which directly contribute to safe pool use and considered through a supervision risk assessment
2. Non-supervisory tasks should be cancelled where there is an unacceptable risk to one or more patrons
3. Tasks related to pool water testing, boom/starting block movements, or change room checks should not be performed by lifeguards during supervision periods
4. A mechanism should be put in place to identify which lifeguard is responsible for which area/s of an aquatic facility during a given period of operation, such as through a structured supervisory matrix, formal hand-over process, differentiated uniforms, or advanced technology tracking
5. Existing supervision risk assessment considerations should be expanded to include instruction on the completion of non-supervisory tasks
6. Patrons should be encouraged to advise staff of any medical conditions or lack of swimming competency upon entry to a facility through membership conditions, website information, entry-based signage, and changing room signage
7. Appropriate signage consistent with Australian standards should provide specific instructions regarding safe use and facility conditions for patrons with disabilities
8. Lifeguards should have appropriate uniform and equipment in place prior to entering the pool area to start their official supervision duties
9. Lifeguard training should emphasize effective supervision and situational awareness as per the updated RLSSA Lifeguarding 5th Edition