Bulletin #92 - Coronial recommendations into death at the Qld Waterpark     


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Recommendation 1
That when items such as inflatable devices are in use in commercial or public pools, pool operators are to conduct a risk assessment on the use of the inflatable before commissioning it. The risk assessment should be conducted in accordance with RLSSA guidelines and take into account all information regarding the inflatable provided by the manufacturer. Following the risk assessment, the pool operator should develop staff training on the issues raised in and procedures developed from the risk assessment and assess staff competency in the procedures.
 
Those procedures should include scenario training relevant to the inflatable device in use. The Division of Workplace Health and Safety is to supervise the implementation of this recommendation.

Recommendation 2
That AFlex Technology Ltd, the manufacturer of the inflatable device in this matter, ensure that the user manual for each device more fully and prominently explain the risks associated with the use of the inflatable device, especially the risk of users drowning, and ensure the manual is provided to the purchaser with the product.

Recommendation 3
That the Division of Workplace Health and Safety consult with industry and RLSSA and give consideration to establishing a Pool Industry Code of Practice as a Standard under the Workplace Health and Safety Act to provide a guide for commercial and public pool owners and operators on issues including risk management and which includes provision for effective monitoring and enforcement of the guideline.

Recommendation 4
That Royal Lifesaving Society of Australia [RLSSA] conduct a review and produce guidelines, to be incorporated into the RLSSA Guidelines for Safe Pool Operation relating specifically to:

(i) the appropriate level of qualification and accreditation of lifeguards, and the required number of lifeguards providing supervision at public pools and "pay for entry" pools;

(ii) that specific reference be made to pools where obstructions including inflatable devices are used as part of the pool business of undertaking.

Recommendation 5
That the Committee responsible for review of Australian Standards AS3533.1 and AS3533.2 review these and other appropriate standards with regard to inclusion of issues around the use of in-water inflatable amusement devices not currently addressed in the standards.

Recommendation 6
That the Department of Health, Local Government Association and RLSSA consider conducting a public awareness campaign, reinforcing the need for continued supervision of children swimming at public pools, by parents, carers, guardians, or responsible adults.

Recommendation 7
That the Department of Health and RLSSA develop a program to promote and encourage parents and guardians to enrol children and other non-swimmers in learn to swim instruction including skills to survive a sudden immersion event.

Recommendation 8
That RLSSA review the ‘Keep Watch’ program with a view to tying the recommendations for supervision not only to age but also to swimming ability levels and require significant enforcement of recommendations by pool staff/owners.

Recommendation 9
That WPHS consider legislating a requirement for all operators of public pools in Queensland to hold membership of RLSSA to ensure operator compliance with safety guidelines offered by RLSSA and to promote greater safety awareness in the industry.

Recommendation 10
That the Queensland Government reconvene a Queensland Water Safety Council including representation from Division of Workplace Health and Safety, Local Government Association, RLSSA, Qld Injury Surveillance Unit and other interested parties, perhaps under the auspices of the Commissioner for Children and Young People, in order to monitor issues and advise government on issues connected with public water safety.

Recommendation 11
That the Local Government Association of Qld and WPHSQ provide access to data involving public pools to RLSSA and approved researchers.

Recommendation 12
That the State Coroner improve the availability of appropriate information regarding drownings to approved researchers at an early stage of the coronial investigation, allowing a more timely review of the event by experts and the development of prevention strategies. It is noted that section 53(2) Coroners Act makes provision for the supply of information in certain circumstances. Timing is the thrust of this recommendation.

Recommendation 13
That WPHS improve the efficiency of the system for the issuing of Safety Alerts or other safety information to industry within a short period of time after an incident in order to protect public safety.

Recommendation 14
That WPHS and QPS:

(i) develop a protocol for QPS officers to contact WPHS inspectors out of office hours in relation to incidents;

(ii) clarify the QPS Memorandum of Understanding with WPHS regarding the investigation of coronial matters and consider modification of the Operations Procedure Manual provisions which prohibit disclosure of information to external bodies without the authority of the Commissioner of Police in this regard;

(iii) Improve communication between WPHS inspectors and investigating Police when investigating a coronial incident.

Recommendation 15
That WPHS ensure that there is continuity of knowledge within the organisation when an Inspector responsible for an investigation leaves before it is complete, so that a report prepared by a subsequent investigator represents the entire details of the incident, and issues such as safety alerts or the dissemination of other safety information are advanced in a timely fashion.

Recommendation 16
That WPHS develop, in conjunction with the State Coroner a more instructive and complete template or instructions to investigators to assist in preparation of coronial reports (reference might be had to the current QPS practice).

            
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