Finding into death of Ze Cheng (Tony) Guan

Life Saving Victoria - Information Submission COR 2014 003658 – Ze Cheng (Tony) Guan Authors: Dr Bernadette Matthews PhD, Principal Research Associate, Aquatic Risk & Research Andy Dennis, General Manager, Public Training and Pool Safety Objectives:  Provide an industry peak body insight into some of the matters raised during the inquest  Provide an overview of current and planned projects associated with public pool safety  Provide recommendations intended to improve public pool safety in Victoria Life Saving Victoria (LSV): LSV has the mission to prevent aquatic related death and injury. The vision is that all communities will learn water safety, swimming and resuscitation, and be provided with safe beaches, water environments and aquatic venues.

LSV (est. 2002) is an initiative of the Royal Life Saving Society Victoria Branch (est. 1904) and Surf Life Saving Victoria (est. 1947). LSV is a registered training organisation, a registered charity and a member of Emergency Management Victoria.

Background: The information contained in this report has been developed jointly by LSV representatives in the ‘Public Training and Pools Safety’ and ‘Aquatic Risk and Research’ areas. It is focused on what are perceived to be some of the key matters pertaining to the inquiry into the death of Mr Tony Guan at the Ascot Vale Leisure Centre in 2014 (COR 2014 003658).

LSV has taken the decision to submit this information based on i) having expert knowledge in the area of aquatic safety and injury prevention, ii) knowledge specific to the facility operation and safety standards at the Ascot Vale Leisure Centre and iii) attendance in court through the inquiry in May 2017. More specifically, this submission is based on, but not limited to the documents listed below. These documents were provided to the facility management and / or the facility owners at the time of their completion.

Pre-Incident LSV Engagement Post-Incident LSV Engagement AFSA -02.12.2009 Critical Incident Systems Review - 05.08.2014 AFSA - 01.02.2012 Design Assessment - 19.03.15 (unrelated) AFSA - 31.01.2014 AFSA - 17.01.17 (unrelated) AFSA: Aquatic Facility Safety Assessment LSV have previously been engaged by the Coroners Prevention Unit (CPU) to provide information into similar incidents. This most recently occurred following the drowning death of Mr. Paul Daniel Rayudu at Watermarc in February 2014, where LSV co-authored the ‘Drowning at Public Swimming Pools Review’1 with the CPU. This document was included as a component of the findings of Coroner Jamieson, which were released on 18 August 2016 (COR 2014 0761).2 1 Coroners Prevention Unit and Life Saving Victoria. (2016). Drowning at Public Swimming Pools Review.

Coroners Court of Victoria: Melbourne. http://www.coronerscourt.vic.gov.au/resources/9fc29ea2-b5bd-499e8b6b-9b0af1b1c6ad/pauldanielrayudu_076114.pdf 2 Coroners Court of Victoria. Finding Into Death With Inquest: Paul Daniel Rayudu. 18 August 2016. COR 2014 0761, Coroners Court of Victoria: Melbourne.

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Following the release of the findings by Coroner Jamieson, LSV were requested to provide recommendations to Emergency Management Victoria on how to initiate improvements in public pool safety. LSV subsequently produced the ‘Drowning Deaths at Public Swimming Pools in Victoria: Working Document’3. The State Government has since committed funding in the recent budget towards the development of a Victorian based ‘Code of Practice’ with LSV acting as the lead agency.

Guidelines for Safe Pool Operation The Royal Life Saving Society Australia (RLSSA) Guidelines for Safe Pool Operation (GSPO)4 is recognised and used throughout the Australian Aquatic Industry as the key reference to water safety and Industry standards. The GSPO was first developed in 1992 and the last review took place in 2013.

As noted in the joint CPU / LSV report from 2014 “In May 2014, RLSSA produced the ‘Guidelines for Safe Pool Operations Review Report.’ The report set out the need for (and intention to) complete a full review of the scope and content of the current Guidelines. Following this a ‘Terms of Reference – National Reference Group’ document was also developed and circulated.” LSV is represented on the National Aquatic Industry Safety Committee (NAISC) by Dr Bernadette Matthews. The NAISC is responsible for the current review of the GSPO. The status of the review as of June 2017, sees three sections released for Industry feedback, a further three sections under development and additional sections in the planning / scoping phase.

Primary Matters Some of the matters raised through the inquiry into the death of Mr Guan were similar matters to those raised in the case of Mr Rayudu. Some of these have progressed based on the formal recommendations from the Findings into the death of Mr Rayudu, whilst others are being progressed within the aquatic Industry by LSV. These key matters are summarised below and make up the body of this submission.

1. Non-Supervisory Tasks Performed by Lifeguards

2. Structured Pool Supervision

3. Supervision of Patrons with a Disability Non-Supervisory Tasks Performed by Lifeguards The completion of tasks other than active pool supervision at the time of the incidents was raised during the inquiries in the deaths of both Mr Guan and Mr Rayudu. These included tasks such as, i) moving lane ropes, ii) plant room checks and iii) water testing (Mr Guan inquiry) as well as iv) moving the pool boom and v) plant room checks (Mr Rayudu inquiry). As a result LSV has proposed to the NAISC and Victorian Aquatic industry that the following provisions are incorporated into the new guidelines to ensure that non-supervisory tasks by lifeguards are:  Limited to only tasks which directly contribute to safe pool use.

 Considered through a supervision risk assessment.

 Cancelled where there is an unacceptable risk to one or more patrons.

 Clearly structured, documented and communicated through staff training.

3 Matthews, B. (2016). Drowning Deaths at Public Swimming Pools in Victoria: Working Document. Life Saving Victoria: Melbourne. http://lsv.com.au/wp-content/uploads/Public-Swimming-Pools-Victoria-WorkingDocument.pdf 4 Royal Life Saving Society Australia. (2013). Guidelines for Safe Pool Operation. Royal Life Saving Society - Australia: Sydney.

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 Not allowed for pool water testing, boom / starting block movements or change room checks.

 Enforced to ensure staff adherence and understanding.

Structured Pool Supervision The matter of who was actively supervising the pool spaces at the time of the Ascot Vale incident was raised throughout the inquiry with three staff present but not noticing the event. This matter was similarly raised during the inquiry into the death of Mr Rayudu. LSV has proposed to the NAISC and the Victorian Aquatic industry that the following provisions are incorporated into the updated guidelines in the GSPO.

 The existing supervision risk assessment considerations are expanded to include instruction on the completion of non-supervisory tasks.

 A mechanism is put in place to identify which lifeguard is responsible for which area/s of an aquatic facility during a given period of operation. This may be by way of, but is not limited to: a structured supervisory matrix; a recognised / formal hand over process; differentiated uniform / equipment; use of advanced technology tracking.

A research project into supervision standards has recently been initiated by LSV in partnership with RLSSA and RLSS Western Australia to further investigate the variables, considerations and challenges which impact supervision. This project will be undertaken in the 2017/18 financial year and the results will be provided to the NAISC for consideration / inclusion in the GSPO.

A new RLSSA ‘Lifeguarding, 5th Edition’5 was released in 2016 and provides further clarification of lifeguard supervision expectations by introducing additional content on ‘effective supervision’ and ‘situational awareness’. These manuals should be provided by all Registered Training Organisations who deliver accredited Pool Lifeguard courses to new lifeguards in Victoria. This role out will assist in the level and quality of information provided to lifeguards as a part of their initial training.

Supervision of Patrons with a Disability The identification of patrons with existing medical conditions / physical impairments was raised in the Mr Guan inquiry, in a similar context to how the identification of weak swimmers was identified during the Mr Rayudu inquiry. It was acknowledged by all parties that these were challenging issue, particularly for those that may not wish to be identified as having a disability or limited swimming competency.

LSV have drafted an initial framework to address these matters. This is based on the approach used to support the provision of appropriate supervision to young children by parents / guardians. These provisions have been presented to both the NAISC and the Victorian Aquatic industry and include ensuring that there is a structure to:  Encourage patrons to advise staff of any medical conditions or lack of swimming competency/ experience upon entry to a facility. This may be by way of, but is not limited to: membership conditions, website information, entry based signage and changing room signage.

 Enable the specific instructions regarding safe use and facility conditions to be provided through the use of appropriate signage consistent with the Australian standard.

 Ensure information is provided advising on pool spaces which are recommended for use by patrons with disabilities (including areas of shallow water) and areas not recommended for use.

 Ensure the supervision provided to other pool users isn't diminished as a result of facility attendance by non/ weak / disabled swimmers.

5 Royal Life Saving Society Australia. (2016). Lifeguarding 5th Edition. Royal Life Saving Society -Australia: Sydney.

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As an outcome of the COR 2014 0761, Belgravia Leisure and Banyule City Council initiated an education campaign to non/ weak swimmers. The initial evaluation of this demonstrated a low level of patron understanding, recall and recollection. Further research is necessary in this area and appropriate funding is required to ensure this work can be undertaken.

Secondary Matters Lifeguard Bum bags / equipment - Lifeguards should have appropriate uniform (on) and equipment (in place) prior to entering the pool area of the facility to start their official supervision duties. Radio equipment may be the exception to this as it is an item handed over at the change of shift.

Lifeguard Numbers - The vast majority of Council owned swimming pools have lifeguard supervision in place at all times. This key safety measure is welcomed by LSV but is also acknowledged to come at a significant expense (approximately $100,000 per Lifeguard position per year).

On the other hand Lifeguards are rarely engaged at non-Council facilities such as, i) swim schools, ii) body corporate facilities and ii) hotels / motels. As a result the Council pools are at a financial and competitive disadvantage and it is important to note that:  The supervision levels provided at Council owned facilities exceeds the standards currently in place at non-Council facilities.

 Recommendations made with the intention of improving water safety should give consideration to both Council and non-Council owned pools in Victoria.

Conclusion The information above is intended to provide an overview of some of the key matters raised during the inquiry into the death of Mr Tony Guan at the Ascot Vale Leisure Centre in 2014 (COR 2014 003658). It is also intended to provide some recommendations for consideration and an insight into some of the progress which has been made since the similar drowning incident involving Mr. Paul Daniel Rayudu at Watermarc (COR 2014 0761).

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