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recurance

Catherine Gibbon

24 Oct 2018 · Coroner ME Hassell · London Inner (North)

The coroner's concerns

  1. 1. lack of assistance understanding medical conditions

    “When Ms [name redacted] joined the gym, she was given a health pledge to read. In this, she agreed to inform a member of staff if she had a medical condition that might interfere with exercise. However, she was not given any assistance in understanding which medical conditions would come in to this category. Even the staff taking her through the health pledge did not have a clear understanding of this.”
  2. 2. lack of staff understanding of epilepsy support

    “There was also no clear understanding across staff of what additional help, if any, could be offered to a swimmer with epilepsy. Any understanding seemed to concentrate upon Ms [name redacted] obtaining a doctor's letter authorising swimming. Whilst there is of course merit in prompting a discussion with a potential swimmer's doctor about the advisability of swimming, Fitness First indicated that constant monitoring of such a swimmer will not be offered.”
  3. 3. lack of CCTV monitoring training

    “The pool was not under continuous supervision and there was no legal requirement for a lifeguard, but it was under CCTV surveillance. The CCTV monitor was in reception. However, no training or guidance was given to the gym receptionist about what she should look for on the monitor and what she should do if all was not as she expected. 2 Most especially, she was not given any instruction as to how frequently to check the monitor”
  4. 4. broken CCTV camera

    “In fact, one of the four cameras had been broken since 24 May. It had not reported and no alternative measures had been taken since it had become non operational. Three minutes and 20 seconds after her seizure began, Ms [name redacted] floated a short distance into the field of the broken camera. From this point, she was completely out of sight of the CCTV monitor.”
  5. 5. absence of panic button

    “There was no panic button that would activate an audible alarm throughout the building, so anyone pressing a button would not know if it had alerted others, and staff elsewhere (other than at reception) would be unaware that there was an emergency.”
  6. 6. absence of poolside landline

    “There was no landline at poolside that could be used to call an ambulance in case of emergency, to enable medical assistance to be summoned immediately by someone who actually had sight of the casualty.”

Responses

No published response was found on judiciary.uk.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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Catherine Gibbon · Recurance