City releases final report on child drowning at Splashville; family’s attorney speaks out.
The city of Stephenville on Friday released the final report detailing what transpired the night four-year-old Colt Williams drowned at Splashville during a birthday party in June.
“Though the report states that the city was in compliance with applicable Red Cross standards for lifeguard training, staffing and facility management based on the information we had as of the date of the report, there are identified areas of improvement in training, facility operations, guest rules and parent knowledge that we will analyze and work to implement in future seasons,” Stephenville City Manager Jason King said in a public statement.
“In addition to these steps to increase the safety of Splashville, the city would like to honor Colt’s memory by implementing a program for no-cost swimming lessons next season. We will provide the details of this program prior to next season’s opening.”
Meanwhile, Dustin Burrows, the attorney representing the Williams family, is speaking out against the report.
“The mayor and city council got what they paid for – an investigation by lawyers specializing in defending city government and a report that likely covers up any wrongdoing by the waterpark. The family has sought at every turn to investigate this matter for themselves; however, they have been denied that opportunity,” Burrows told Beneath the Surface News.
“Our hope was that a real investigation would shed light on any negligence by the waterpark and corrective measures could be taken to prevent future tragedies. However, the mayor, council and their lawyers care more about the appearance of looking good than doing the right thing.
SCROLL TO READ THE FULL REPORT:
TO: CITY OF STEPHENVILLE CITY COUNCIL DATED: OCTOBER 12, 2023
INVESTIGATION OF DROWNING AT SPLASHVILLE FACILITY.
The law firm of Taylor, Olson, Adkins, Sralla & Elam, LLP, was retained by the City of Stephenville to investigate the drowning incident that occurred at the City of Stephenville’s public swimming pool, known as Splashville, on June 24, 2023 and to examine the policies and procedures of the Splashville facility to determine the cause of the incident and whether any Splashville procedures should be amended to enhance facility safety and prevent future incidents. This report details our findings, conclusions, and recommendations.
I. FACTUAL BACKGROUND
On June 24, 2023, the Williams family, Cassidy Williams and her two sons, Colt (4) and Barrett (5), attended a private birthday party hosted by another family, held at Splashville. The private party was scheduled from 6:00 p.m. to 8:00 p.m., after Splashville had closed to the public.
Approximately 100 guests were in attendance. Splashville has a maximum capacity of 660 people. All features of Splashville were available to the guests at the party. Eleven lifeguards were engaged by the City to operate eight lifeguard stands during the party, which allowed for alternating break stations.
At approximately 7:30, party guests began to exit the pool for dinner of hotdogs and pizza. Many families removed the life jackets of their children to allow them greater mobility while eating.
At approximately 7:40, a father notified a lifeguard at station 3 that his child had seen a baby in the pool. The father could not see the child but pointed the lifeguard to a general direction near the lily pad obstacle course where his child indicated the baby had been seen.
Upon viewing the pool, the lifeguard was also unable to see a child in the water from his position and signaled by a two-whistle tweet that he was leaving his position. The lifeguard then got in the water to search.
At that same time, another guest across the pool noticed the conversation between the father and the lifeguard. The father had been pointing in the direction where the guest was sitting.
The guest went to the edge of the pool and scanned the bottom of the pool, but did not see anything in the middle of the pool. However, when he looked straight down, he was able to see a child at the bottom of the pool with arms and legs outstretched. The guest jumped in the pool and was able to remove the child, who had not been wearing a life jacket or any type of flotation device.
At this time, lifeguards sounded a triple tweet whistle to activate Splashville’s emergency action plan (EAP). Guards who were on break and nearest the automated external defibrillator (AED) retrieved the AED and delivered it to the location of the child.
The guest who pulled the child from the pool immediately began CPR. Though lifeguards attempted to take over CPR, the guest, a West Point graduate and officer in the Texas National Guard who had combat lifesaving training, continued CPR until a police sergeant arrived who continued CPR for a short period of time before paramedics arrived.
The lifeguards were able to retrieve the AED quickly, removed the child’s shirt, and applied the AED pads to his chest and back.
The AED provided directions on the rhythm to administer CPR to the child. Although the AED automatically checked for a heart rhythm to administer an electronic shock to the child, no heart rhythm was ever detected. The guest did provide mouth to mouth resuscitation to the child, at which time a large amount of recently chewed food was expelled.
Witnesses, fire fighters, paramedics, and guards assisting in providing the child life saving measures indicated there was no response or sign of life from the child.
It is unclear how the child, identified as Colt Williams, was in the pool. He had left the pool with his family to eat, at which time his life jacket was removed. In her conversation with attending officers, Ms. Williams (Colt’s mother) indicated she was unsure how long Colt had been out of her presence before he was discovered in the pool.
No adults or lifeguards witnessed him enter the pool. In our investigation, we were made aware of one five-year old child who made an outcry to their mother asking why the boy would jump in the pool without his life jacket. The child observed Colt jump in the pool near the obstacle course and did not observe him resurface.
The child told their mother that Colt did not splash when he jumped in and that the child observed juice come out of his mouth when the adults were pushing on his chest.
Texas Rangers and Stephenville Police conducted an investigation immediately following the drowning. Life guards, responding fire fighters and paramedics, and select guests involved in life saving measures were interviewed. The Rangers and police department concluded the incident was an accidental drowning.
II. SUMMARY OF CONCLUSIONS
Based on our investigation, we found no evidence that anything untoward or any negligent behavior on the part of lifeguards occurred that contributed to the child’s drowning. Splashville was operating with a number of life guards in excess of Red Cross minimum standards.
All lifeguards were certified by the American Red Cross and adequately trained for their positions. Splashville had posted rules for guests that, if followed, were sufficient to prevent this incident. This was a tragic accident. Nevertheless, this incident occurred despite Splashville operating in accordance with recognized recommended guidelines.
Therefore, we are providing at the end of this report recommendations for the implementation of future policy and procedure updates based on information derived from our investigation and suggested actions given by a lifeguard training expert.
The first call to 911 went out at 7:48:53 p.m. Fire fighter testimony provided to the Texas Rangers indicates that emergency personnel began arriving on the scene at 7:52 p.m.
III. INVESTIGATION METHODOLOGY
The investigation was conducted by reviewing the investigation reports of the Texas Rangers and the Stephenville Police Department. Additionally, we watched all interviews conducted with fire fighters and paramedics, lifeguards, and witnesses. We reviewed Red Cross policies and lifeguard manuals and interviewed an expert lifeguard trainer certified through the American Red Cross.
In addition, we interviewed all lifeguards who were on duty at the time of the incident. We requested interviews with a number of guest witnesses and were able to interview twelve guests, including the party hosts. Finally, we interviewed BJ Hill with the Texas Rangers.
Due to the incident occurring at a private party, the city does not have the name of all patrons in attendance. Though we requested assistance with names of additional attendees to interview from those we interviewed, as of the date of this report, we have interviewed all patrons whose names we were provided that agreed to speak with us.
Similarly, we understand from the witnesses interviewed that additional videos and photographs may exist, however, as of the date of this report our requests for copies of those additional videos and photographs have been declined.
We also requested the opportunity to speak with the Williams family. The family is represented by an attorney, who denied our request.
IV. REGULATION OF PUBLIC POOLS A. Overview of the Regulation of Pools
The State of Texas regulates pools broadly under the Health and Safety Code, Sections 341.064 and 341.0645. These sections require the Executive Commissioner of the Health and Human Services Commission to adopt safety standards necessary to prevent drowning which must be at least as stringent as those imposed under the Federal Virginia Graeme Baker Pool and Spa Safety Act.
The Executive Commissioner must also adopt by reference a version of the International Swimming Pool and Spa Code, which is also guaranteed to be more stringent than the Graeme Act. The adopted safety standards and regulations within the International Swimming Pool and Spa Code are found within the Texas Administrative Code.
1. Title 25 Health Services, Chapter 265, Subchapter L, Administrative Code
The Texas Administrative Code provides requirements pertaining to lifeguards, emergency devices, and training. Under the Administrative Code, public pools owned by a municipality that are maintained or used for public recreation and are open to the general public, with or without a fee, are Class B Pools. The following standards are applicable to Splashville, a Class B pool, specifically relating to lifeguard and emergency safety:
Class B pools that are over 5 feet deep must have a four-inch minimum width row of floor tile at the transition point to the deep area, and a rope and float line between one and two feet on the shallow water side of the five-foot depth. (The Splashville pool is less than 5 feet deep.)
Depth markers should be in the top 4-1/2 inches of the pool wall and positioned to be read by a person in the pool, four inches in height minimum, and permanent.
Where “No Diving” markers are required they must be a minimum of four inches, prominent in color, permanent, and slip resistant (Figure 25 TAC §265.190(f)(5) provides that markers are needed where no lifeguard is required or provided).
Safety signs must follow the figure included in Chapter 265, which provides letter sizing for certain warning signs. Also, in areas where the majority of the residents are non-English speaking the signs must also be in the predominant language.
A pool must have at least one ring buoy with a rope and a reaching pole for every 2,000 square feet of surface area.
A pool must have at least one emergency phone, contacting device, or alternative system for summoning emergency services within 200 feet of the water. A fixed-location emergency communication device must be visible, have no obstructed access, and have a sign posted above it with the location of the pool in one-inch letters.
Lighting must be provided if the pool is open 30 minutes before sunrise or 30 minutes after sunset.
A minimum of two lifeguards must be available at a Class B pool (not necessarily on duty at the same time, just at the facility). There must be a staffing plan that includes rotation of guards if they are given a break, and each lifeguard must have an assigned surveillance area that they are able to view in its entirety. Lifeguards must be trained persons and records of their certifications kept. Alertness and response drills and any other training is required including: a pre-season training program; continual in-service program of at least 60- minutes per 40 hours of employment; review of CDC standards for stool contamination; performance audits as recommended by the ARC, YMCA, or equivalent safety organization; and review of facility emergency action plans.
Pools must have an emergency plan that includes a list of emergency numbers, first aid kit and other rescue equipment, a response plan for inclement weather, and a plan for responding to bodily stool or blood contamination.
Lifeguards must have access to at least one OSHA compliant first aid kit, one backboard with head immobilizer, one portable AED, and one bag valve mask (BVM).
If the pool depth is greater than five feet there must be an OSHA compliant lifeguard stand with a sunshade and unobstructed view of the water.
Lifeguards must be provided a uniform, a rescue tube or floatation device, protective rescue gear such as gloves and a resuscitation mask (or “breathing bag”), and a whistle or other signaling device.
All pools must be maintained under the direction of a properly trained and certified operator. The training/certification may be from the NPRA (aquatic facility operator), PHTA (certified pool operator), ASPSA (licensed aquatic facility technician), or an equivalent. The operator does not have to be on site.
The water in a pool must be sufficiently clear to see the bottom while the water is static.
B. Safety and Training Organizations and Plans
The United States Lifeguard Standards Coalition is comprised of the American Red Cross, the United States Lifesaving Association, and the YMCA. These organizations have partnered to perform studies to determine best practices for lifeguard training programs.
Stephenville requires lifeguards to complete American Red Cross training and receive their certification prior to being on stand as a lifeguard.
Based on our review of American Red Cross training manuals and our interview with a lifeguard training expert, Splashville should comply with the following Red Cross standards:
1. Red Cross Lifeguard Requirements
The Red Cross provides minimum standards for lifeguard certification. A lifeguard must be at least 15 years old and pass swimming requirements. Potential lifeguards must attend a two to three-day training course given by a certified lifeguard trainer.
The course includes training on administering CPR and use of an AED; first aid; victim assessment; injury prevention; rescue skills; and care for head, neck, and spinal injuries. The skills and response training occurs not only in instruction format, but the trainees must also practice these techniques and rescue skills in the pool and demonstrate proficiency prior to being certified.
A trainee will not pass the course unless they demonstrate to the certified lifeguard trainer that they have proficiency in skills assessed, pass all rescue scenarios, show maturity, are able to effectively communicate, and are proficient in the water. If the trainee demonstrates these necessary skills, they receive a two-year First Aid and CPR/AED certification and a two-year Lifeguarding certification.
2. Red Cross Lifeguard Manual on Recognizing Drowning
As part of the certification, lifeguards are trained on responding to drowning scenarios. The Red Cross recognizes various types of drowning. First, there is active drowning. In these situations, the victim will struggle to remain at the surface of the water and exhibit the “instinctive drowning response” where arm movements and body positions are instinctively used to keep the victim’s mouth above water. In these situations, some visible indication of struggle is viewable at the surface of the water.
Other drowning situations occur where there is no struggle but the individual slips under the water. These are considered passive drowning victims. The Red Cross notes that passive drowning victims can be difficult to see due to glare, reflections, or water movement from the wind or other swimmers. Often these victims, when viewed, look like a smudge, an object like a towel, or a shadow. They may be discovered face-down at the bottom of a pool.
3. Zones of Surveillance
To recognize drowning situations, the Red Cross provides guidance on the number of lifeguards required for surveillance and a lifeguard’s zone of surveillance responsibility, referred to as a zone. At least one lifeguard is required for every 25 swimmers. Each area of a pool is assigned a specific zone, with one zone for each lifeguard station.
Lifeguards should have unobstructed views of their zone from each station. Additionally, each lifeguard should be able to reach a victim in the furthest and deepest area of their zone within thirty seconds. These response times should be tested frequently during the season and adjusted as necessary.
Splashville has multiple water features, including a pool, zero depth wading area, water slides, lazy river, lily pad obstacle course, and splash pad. The facility split into zones with stations monitoring specific water features as indicated in Illustration 1:
Zone coverage is effective for high-risk areas or activities, avoiding blind spots, and reducing the number of guests watched by each lifeguard. The Splashville lifeguards had received prior training on the stations and the zone of responsibility for each station.
With the exception of Station 1, the Splashville stations are ground-level stations. Ground- level stations place lifeguards in close proximity to guests to easily make assists and enforce safety rules in the water and on the deck. Lifeguards in these positions are also able to educate guests about reasons behind facility rules.
Facilities should have a defined rotation procedure for the stations. Rotations include moving lifeguards from one station to another, as well as giving lifeguards breaks from surveillance duty.
Red Cross advises that typical rotations require a lifeguard to serve at a station for 20-30 minutes, rotate to the next station for 20-30 minutes, then have a 20-30-minute break. The rotations at Splashville operate as 15 minute intervals at each station, with breaks at stations 4, 9, and 13 (or station 12, based on staffing). Lifeguards on break are expected to immediately respond in the event the EAP signal is activated.
When rotating, Red Cross advises that the rotation begin with a lifeguard coming off break. Each lifeguard is responsible for ensuring there is no lapse in guest surveillance prior to taking over a station. The outgoing guard should inform the incoming guard of any situations that need special attention then continue scanning while making their way to the next station.
4. American Red Cross for Parents
In addition to lifeguard standards, the Red Cross provides water safety training for parents, caregivers, and children. Red Cross advocates making water safety a priority at all times. Water safety includes paying close and constant attention to children you are supervising, even when a lifeguard is present, no matter how well the child can swim or how shallow the water.
A parent should be within arm’s reach of young children and require that weak swimmers wear U.S. Coast Guard-approved life jackets when near water. Parents should not rely on the use of water wings, swim rings, inflatable toys, or other items designed for water recreation to replace adult supervision. Parents are advised to avoid distractions, including cell phones. The Red Cross advocates water acclimation and readiness courses for toddlers and learn-to-swim courses for children of all ages.
C. Splashville Rules and Regulations
Splashville has rules and regulations for each feature of the water facility. Additionally, the facility has guest rules posted at the facility entrance. These rules include the following:
· Children age 10 and under must be accompanied by an adult age 16 or older;
· Children must be at least 42” tall to participate in the lily pad, tower water slides, and lazy river;
· A parent/guardian must be within arms-length of children who are unable to swim;
· U.S. Coast Guard approved flotation devices only in the pool;
· Must wear a PFD (personal flotation device) if unable to swim;
· Please do not talk to lifeguards on duty (except to report an emergency); and
· A swim test may be conducted at the lifeguard’s discretion.
Signage notifies guests that they must obey all park rules and follow the direction of lifeguards. Failure to do so may result in employees ejecting or suspending any person from pool property. Splashville also provides U.S. Coast Guard approved PFDs for guest use.
V. WITNESSES INTERVIEWED
We interviewed all lifeguards on duty on June 24, 2023 and twelve guests who attended the private event. Additionally, we reviewed interviews of guests and emergency responders conducted by the Texas Rangers and the Stephenville Police Department.
Due to the incident occurring at a private party, the city does not have the name of all patrons in attendance. We requested interviews with a number of guest witnesses and were able to interview twelve guests.
As of the date of this report, we have interviewed all patrons whose names we were provided that agreed to speak with us. We also requested the opportunity to interview the Williams family, but our request was denied by their attorney. A summary of the persons interviewed is provided:
A. Lifeguard interviews
At the private event on June 24, 2023, there were eleven lifeguards on duty, including two head guards and a manager that was acting as a lifeguard. Our interviews focused on each lifeguard’s training, facility operations, and the evening of June 24, 2023.
Our investigation revealed that all eleven lifeguards on duty had received their lifeguard certification prior to being on stand on June 24, 2023. The lifeguards described their training as a two-day course. The first day was spent reviewing training videos focused on CPR, AED administration, and emergency responses. They then performed CPR skills assessment. The second day was focused on in-pool response training.
They practiced back boarding, drowning responses, safely removing guests from the pool, and administering CPR to dummies. The training was conducted by a certified lifeguard trainer, who analyzed the lifeguard’s demonstrated skills, maturity, and swimming proficiency. Those who demonstrated proficiency in the training received their lifeguard certifications.
After the Red Cross certification training, the lifeguards were required to attend facilities training, called “in-service”. There was an extended in-service training prior to the opening of the season (2023 opening was Memorial Day). This in-service included teaching the lifeguards the specific Splashville zones, how to scan at each zone, the emergency action plan for Splashville, additional back boarding and emergency response training, refreshing on CPR and AED administration, how to clean the facility, and conditioning. These trainings were provided by Splashville managers.
The lifeguards were expected to attend weekly in-service throughout the season. In-service was held on Tuesday evenings. Lifeguards reported that not all guards attended the weekly in- service, and those who missed may receive punishment ranging from additional conditioning to not being provided hours of work. The weekly in-service was an opportunity for the facility managers to address training concerns, provide training refreshers on administering CPR and the AED, and run additional emergency response scenarios. Lifeguards indicated that in-service was also used as a time to clean the facility.
When asked if they felt the training was sufficient, a few lifeguards expressed their concerns that not enough facility training was received prior to the season opening. Part of this concern was derived from this season’s hiring process, where new guards were hired after the season opened, not allowing all guards to have the extended season opening training.
Additionally, some guards did not feel confident in the stations and what was expected of them at each station prior to their first shifts. We were informed that the first few days of the season, where students from area schools attended the pool for class trips, were particularly stressful. However, as they attended more in-service and received additional instruction, the lifeguards were more confident in their positions after the first or second week of the season.
The lifeguards described their shift selection, shifts, and breaks. Shifts are chosen by the lifeguards based on their availability. At the beginning of the season, they were required to sign up for shifts in person on a tablet or respond to a request for coverage posted in a GroupMe app conversation thread. However, as the season progressed, they were provided an app called DigiQuatics where they could sign up for shifts and the app would monitor their hours worked per week.
Lifeguards were limited to forty hours worked per week.
They had the option to sign up for full-day shifts or half-day shifts. We were told by most lifeguards, unless they had a conflict, they preferred to work full-day shifts and to work as often as possible. In the event a private party was booked after hours, the lifeguards working the afternoon shift were expected to stay and work the private party as well. One manager indicated that there was difficulty being fully staffed this season.
Times that they did not have thirteen guards, they would remove station 12, station 1, have a cashier (who need not be a lifeguard) serve at station 5 (top of the slides), or close the lazy river, as needed.
During their shifts, lifeguards would be on-stand for approximately 45 minutes and then receive a 15-minute break. During their break, they were expected to be attentive in the event the EAP was activated. Lifeguards on break were expected to be in the air-conditioned guard room, where they would eat, rest, and cool off, or they were permitted to float in the lazy river, swim, or use the water slides provided they had removed their whistles, packs, and rescue buoy.
Lifeguards were not permitted to have their cell phones or smart watches on their person while on stand.
They were allowed to keep their cell phones in the guard room and only check them while on break. They were not permitted to take their cell phones out of the guard room even during their break time. Each lifeguard we interviewed took this rule very seriously.
3. Emergency Action Plan
The lifeguards were well versed and confident when explaining their warning signals and emergency action plan. The notification whistle signals are used as follows:
One tweet – used to get a guest’s attention who is not following rules; most often used to notify children to stop running;
Two tweets – notifies the head guard the lifeguard needs assistance. Two tweets are used in a range of circumstances such as when a lifeguard feels dehydrated and needs to request water, when a guest is combative and will not follow the lifeguard’s rules it signals the head guard to step in and allow the lifeguard on stand to return to monitoring their zone, and it signals a head guard and other lifeguards that there is an active response situation where the lifeguard will be leaving their station to enter the water to provide assistance and other guards need to expand their surveillance area;
Three tweets – initiates the EAP (emergency action plan). In this situation, the cashier is to call 911 lifeguards on break are to grab the AED and towels from the guard room and quickly take them to the emergency area; lifeguards in other areas of the pool begin removing all guests from the pool, lazy river, and splash area; and responding lifeguards provide life saving assistance.
4. The Incident
On July 24, 2023, there were eleven lifeguards on duty at the private party. Most of these lifeguards had worked the entire public shift. The lifeguards indicated that it was the largest private party they had worked, but was similar in the number of guests to a regular day.
They recalled that the children ranged in age from babies to young teens, but were predominately young children, under ten-years old. A large number of parents were in the pools with their children.
As the private party was winding down, a lifeguard who was going on break recalled taking a child who had hit his head to the guardroom for assessment. A headguard/manager left station 2 to assist.
During this time, the lifeguard at station 3 was addressing parents who were placing their children on or over the wall that bordered the splash pad area and large pool.
As he was dealing with parents on the wall, a parent approached the lifeguard at station 3. The father stated that his son had seen a baby in the water and pointed across the pool.
The lifeguard indicated they first looked at the top of the water and did not see a body. Additionally, the lifeguard could not see anything below water from their position, so the lifeguard double tweeted to signal the lifeguard at station 7 that they were entering the water so that guard could expand their surveillance. The lifeguard entered the water and began scanning toward the direction the father had pointed.
At this time, a male guest entered the pool and pulled out a child. The lifeguard described the child as motionless, his face was purple or blue, and he was not wearing a flotation device. The lifeguard stated that the guest told the guards he was certified in CPR and would not permit the guards to administer CPR. While the guest was performing CPR, the lifeguard ran to the guard room to help get dry towels.
After, the lifeguard assisted with removing guests from the facility.
The lifeguard at station 7 stated they heard the station 3 lifeguard two-tweet and signal that they were going in the water. The station 7 lifeguard expanded their surveillance zone.
They saw a guest pull a child out of the water before the lifeguard at station 3 could arrive. The area where the child was found was shaded and difficult to see the bottom and they did not see a child at the bottom from their location. Once the triple tweet sounded, the lifeguard helped evacuate the pool and then remove guests from the facility.
Hearing the double tweet, the lifeguard at station 6 turned from monitoring the slides to assess what was needed. The station 6 lifeguard saw a guest in the pool removing a child. The lifeguard at station 6 swam over to where the child had been removed, told the lifeguard at station 8 to activate a triple tweet, and yelled for an AED.
The lifeguard assisted in moving the child further away from the pool’s edge to allow for CPR to be administered.
The lifeguard indicated that the guest who had removed the child from the pool would not let the lifeguards perform CPR but did inform the lifeguards he was certified to administer CPR.
The lifeguard assisted with placement of the AED that had been brought to the child’s location. After applied, the station 6 lifeguard helped remove guests from the facility.
The lifeguards on break heard the triple tweet and immediately responded by grabbing the AED, air bags, and dry towels in the guard room to dry the child before placing the AED pads. When they arrived at the location of the child, a guest who the lifeguards believed to be the child’s father, was already performing CPR on the child.
The lifeguards informed the guest that in order to use the AED the child’s shirt needed to be removed. They lifted the child’s shirt over his head, placed the AED pads on his chest and back because his chest was too small to apply two pads, and operated the AED while the guest continued CPR. The lifeguards never saw signs of life from the child.
The lifeguard at station 5 indicated they heard the two-tweet whistle then looked into the pool and observed a guest removing the child. When the triple tweet sounded the lifeguard removed any kids trying to go down the slides and ran to the guard room to help retrieve towels and the AED. Once the guards on break were taking the AED, towels, and breathing bag to the emergency scene, the lifeguard assisted evacuating all guests from station 2.
When the triple tweet sounded, the lifeguards at stations 10 and 11 began removing guests from the lazy river. Once that portion of the facility was cleared, they assisted removing guests from the facility.
The lifeguards indicated that the seating areas near where the child was found were crowded and chaotic at the time the EAP was activated. Additionally, we were informed that at that time of day, the sun casts a glare on the water in the area where the child was found that makes it difficult to see the bottom of the pool.
5. Witness Interviews
The witnesses interviewed were the hosts and guests of the private party that was held at Splashville. We were informed that it was a large private party, having up to 100 guests.
No persons interviewed indicated they personally observed any actions of the lifeguards that indicated they were distracted in their duties. Most witnesses described the party as feeling like a normal day at Splashville, where lifeguards were at their posts, attentive, and whistling at guests who were not complying with pool rules.
When the incident occurred, the witnesses informed us that most people were out of the pool and eating. Most of the children who were eating were no longer wearing their floaties or life jackets. Some witnesses recall hearing whistles, others did not recall but stated it was not something they were listening for. No adult witnesses recalled seeing how the child entered the pool.
One witness informed us that their five-year old child made an outcry that they saw the child jump in the pool near the obstacle course. The witness’s child said that when he jumped in, they were not splashed and the child did not come back up. The witness’s child asked why he would jump in the pool without his life jacket. The witness’s child recalled seeing adults push on the child’s chest and that juice came out of the child.
The guest who removed the child from the pool indicated he had his back to the pool and was eating with his family. He noticed his wife staring in the distance and followed her gaze to what was occurring at station 3.
He observed a father talking to the lifeguard and pointing in the water. The guest immediately left the table and went to the edge of the pool, near the lily pads, and started to scan the bottom of the pool. He did not see anything in the middle of the pool. He looked at his feet and saw a child at the bottom, face down, with arms and legs sprawled.
The guest, a veteran with combat lifesaving training, jumped into the pool, pulled out the child and started CPR. He indicated that he was focused only on the child and took immediate action. He informed us that the lifeguards quickly retrieved the AED and it was placed on the child. His CPR actions fell in sync with the AED, which would check for heart rhythm, but never administered a shock. The guest gave the child mouth-to-mouth resuscitation rather than using a breathing bag (a breathing bag/resuscitation mask may be used if the person who administers CPR is uncomfortable performing mouth-to-mouth).
The mouth-to-mouth resuscitation caused the expulsion of a large amount of recently chewed food. With the exception of a short break provided by a police sergeant, the guest provided CPR until paramedics arrived. Other guests we interviewed stated the guest administering CPR appeared to have gone into his military training and they do not believe anyone could have removed him from performing CPR on the child.
Another witness with firefighting training informed us that based on his training, the AED was working correctly. He stated the AED did not shock the child, which indicated there was no heart rhythm or electric pulse to trigger the AED to shock.
Witnesses confirmed that when the child was removed from the pool he was not wearing a life jacket or flotation device. He was wearing a swimming top that was blue and blue trunks with some orange.
There are conflicting reports about lifeguard response to the triple tweet. Three guests recalled not seeing any lifeguards responding to the scene. This was in direct conflict with the report provided by the guest who performed CPR and other guests that told us they did not see any lifeguards not doing their jobs.
These guests explained that when one lifeguard called, they all came running.
A repeated reflection from the witnesses was that there were so many parents present, it was hard to understand how no one saw the child enter the pool.
Witnesses raised a number of concerns ranging from the age of the lifeguards, increasing the number of lifeguards, setting up zones to avoid blind spots, removing the lily pad obstacle course, and setting up cameras around the pool area.
A number of witnesses questioned why the City had not provided resources to those in attendance at the party, specifically asking for counseling recommendations.
We are aware that the City Manager did provide a list of available therapists to the party host in July, as the hosts are the only persons with knowledge of who attended the event.
6. Fire Fighter and EMS Interviews
The Texas Rangers interviewed fire fighters and EMTs who responded to the scene. We reviewed the recordings of those interviews.
All emergency responders indicated that quality CPR, with good compressions, was in progress when they arrived on scene. An AED was attached to the child, which indicated no shock was advised. The EMTs advised they replaced the facility AED with their AED, which also had no shock advisory.
CPR and compressions continued while the child was transported to the hospital. The firefighters and EMTs indicated there were no signs of life, cardiac activity, or response from the child.
Based on our investigation, the City has complied with Red Cross standards for lifeguard training, staffing, and facility management. Additional and continual trainings before and throughout the season will ensure lifeguards are maintaining their skills and certification and provide greater protection to guests.
Our investigation found that there were an adequate number of lifeguards on duty at the private event on June 24, 2023. The lifeguards were attentive and despite some criticism of the lifeguards in general not saving the child, no witnesses interviewed personally observed them being distracted or not being diligent in their duties.
From the witness interviews as a whole, we concluded when the lifeguards were notified of a child in the pool, they responded appropriately, activating a two-tweet signal, and then a triple-tweet when the child was found. The lifeguards responded in compliance with their training when the EAP was activated, but allowed a guest who asserted control over the situation and stated he was certified in providing CPR to continue to provide CPR to the child.
Our investigation found that the Splashville facility was compliant with Texas Administrative Code standards applicable to class B pools though we did get conflicting information concerning whether the lifeguards consistently received at least sixty (60) minutes of in-service training for every forty (40) hours worked.
Aside from one five-year old child, no guest or lifeguard saw the child enter the pool.
Although we have found no specific failings of the facility or lifeguards that caused this incident, based on our investigation, and the input from lifeguards, witnesses, and a lifeguard training expert, the following are recommendations the City may consider implementing at Splashville to increase safety for future seasons:
Hiring and Shifts:
· Open hiring by March.
· Consider team shifts, where one group A works set days and group B works set days to avoid lifeguards having to work back-to-back days. Training:
· Begin in-service trainings as soon as lifeguards are certified to allow lifeguards the opportunity to be fully trained and comfortable with their responsibilities at each zone prior to season opening.
· All in-service trainings should be conducted by a certified lifeguard trainer.
· In-service should be mandatory. Guards who do not attend must make up the training prior to being allowed on stand.
· In-service should be documented, detailing which guards attended and the training provided at each in-service.
· Head guards and managers should be attentive to where lifeguards exhibit weakness and provide additional one-on-one training before or after shifts.
· Conduct live-action recognition drills during regular hours. These drills use a mannequin (or guest, with parent permission if a minor) to simulate an active rescue situation. Notice should be posted advising guests that drills will be conducted during open hours.
· Employ certified lifeguard trainers to conduct reviews of lifeguard operations during regular hours and provide feedback of weaknesses to be improved. Facilities and Zones:
· Consider placing cameras covering the pool areas.
· Zones should be tested frequently throughout the season to ensure guards can reach the furthest, deepest area of their zone within 30 seconds.
· Consider the effect of the sun at different times of the day when scheduling pool hours. If the sun casts shadows or causes a glare in the evening of early season months, consider not allowing private parties after hours until July.
· Have Station 1 manned at all times.
· Consider adding a station on the main pool, near the handicap access chair.
· Consider allowing a cashier to man the top of the slides, rather than a lifeguard.
· Consider removal of the lily pad obstacle course and pillars that could block visibility.
Guest Rules and Parent Knowledge:
· Consider requiring all children under 42” to wear a life jacket.
· Provide parent information regarding water safety on the Splashville website: https://www.redcross.org/take-a-class/classes/water-safety-for-parents-and-caregivers/a6R3o0000012oT8.html
· Consider posting additional signage to remind guests of pool rules.
· Consider encouraging parents to have their children utilize U.S. Coast Guard approved flotation devices available at the facility.
· Consider mounting TV monitors to play pool rules and other important guest information at the facility entrance.
It is our understanding that the City has already implemented the following changes:
· Cameras of the facility have been installed;
· Funding has been approved for a full-time aquatics manager; and
· The City is pursuing enhanced lifeguard training and monitoring from a new service.
cc: Jason M. King, City Manager
City of Stephenville, Texas Email: firstname.lastname@example.org
Very truly yours,
Ashley D. Dierker