Abubbaker Aziz

Contributing factors

• Inadequate pool supervision
• Pool Manager (Adam Wild) leaving facility at 4:20pm leaving only one lifeguard on duty
• Sole lifeguard (Julie Jones) responsible for supervising four pools across approximately 100 metres
• Breach of Royal Life Saving Society of Australia (RLSSA) Guidelines for Safe Pool Operations
• Breach of contractual obligation requiring two lifeguards on duty at all times
• Diving pool not provided with direct or primary supervision
• Deceased undetected on bottom of diving pool for approximately 20 minutes
• Area Manager (Gary McAllister) signing off on inadequate rosters and being aware of inadequate supervision occurring at times

Coroner's recommendations

1. RLSSA Guidelines for Safe Pool Operations require refinement, particularly regarding supervision and definition of 'low patronage pools' which should be determined solely on usage and design of facility with independent assessment
2. Amend RLSSA Guidelines to require direct and primary supervision of diving pools when open, with both lifeguards occasionally scanning other pools
3. RLSSA Guidelines should specifically address patron supervision of diving pools in Pool Lifeguard course and annual reaccreditation including written examination and testing scenarios
4. Require thorough induction process by aquatic manager for each new employee prior to first shift regardless of experience, as each facility is unique in design and patronage
5. Amend RLSSA Guideline regarding parental supervision to raise age limit from children under 10 years to children under 15 years for unsupervised entry (though coroner questioned the appropriateness of age limitation)
6. Seek funding to conduct Swimming Pool Safety Assessments (SPSAs) on ongoing basis as means of ensuring compliance with Guidelines for Safe Pool Operation and enabling RLSSA to recommend minimum number of lifeguards for each facility
7. Conduct wide-ranging review to advise responsible Minister on whether formal statutory regulation of aquatic industry is necessary, as alternative to current self-regulation under RLSSA Guidelines
8. Consider hybrid regulatory model where RLSSA exercises formal policing, investigative and prosecutional role, or formulate Guidelines into legislation, regulations or Australian Standards with enforcement process similar to SPSAs
9. Pool Safety Assessments should be considered as part of performance criteria or management contractual requirements to provide independent evaluation of contract manager's compliance to industry best practice