Girl Dies at Swimming Pool in Leicestershire - Lifeguard Training Criticised by Coroner

 A sixteen year old swimmer died in a pool in Braunstone Leisure Centre in Leicestershire last September. The Mail, BBC news and other have reported that she could have been saved with better training.

The Mail reports:

 

Miss Butler (the lifeguard) who had never tried to revive a swimmer before, believed she had saved Sophie when she started breathing again.However, she did not take the crucial step of checking for a pulse - to determine whether the heart had restarted - and unwittingly left Sophie dying on the wet floor. Paramedics arrived four minutes later and resumed CPR, only to be asked by one of the lifeguards: 'Why are you doing CPR? She's alive,' the hearing was told. As a paramedic gave evidence to the inquest, the teenager's distraught mother, Lesley, 46, broke down in tears and cried out: 'It's my child's life, why didn't anybody do anything?

 

'How could you just leave her lying there? She would have survived.'

The ambulance crew tried to revive Sophie, a talented swimmer who dreamed of winning an Olympic gold, with a defibrillator at the leisure centre in Braunstone, Leicester, on September 15 last year. However, she was pronounced dead shortly afterwards at the city's Royal Infirmary. The inquest heard Sophie's initial cardiac arrest was caused by an undiagnosed heart condition.

Heart expert Dr Christopher Duke said Sophie 'would have survived' if she had received continuous CPR. He said: 'You don't stop resuscitation just because a patient appears to be breathing. You only stop if there's breathing and a pulse. The inquest on Wednesday heard that Miss Butler, who was employed by Leicester City Council and was performing CPR for the first time, spent four minutes trying to revive Sophie and believed she had succeeded when the teenager began breathing.

She said: 'If a person is breathing we're told to stop CPR and put them in the recovery position.' Sophie's heart was not restarted by defibrillator until 4.52pm - 14 minutes after she was pulled out of the pool. The inquest heard the lifeguards had been trained by the Royal Life Saving Society, a charity which provides training and education in lifesaving. Recording a narrative verdict, coroner Catherine Mason said she would write to the Resuscitation Council of the UK, which provides guidelines for life-saving techniques, to ask it to amend its training guidelines to include checking for a pulse. Mrs Mason, coroner for Leicester and South Leicestershire, said: 'The crucial point of this is that the CPR was stopped.

 

'The guidelines should be changed so that from when CPR commences it is conducted until a medically qualified person arrives or the patient regains consciousness.'

After the inquest, Mrs Konderak and Sophie's father, John, said the 'shortfall in the level of training and equipment' contributed to their daughter's death. They added: 'We hope the coroner's recommendations will lead to an improvement in lifesaving training and no further lives will be lost.'

 

 

The Association of First Aiders have also been asked to comment on this incident. They have stated:

The casualty could have easily re-arrested causing death. Detecting a pulse (or the absence of one) would have identified the need to continue CPR. However, it is feasible the first aider misinterpreted 'Agonal' breathing (which is a sign of dying) with 'Normal' breathing (a sign of life). If this is the case, ineffective training may be the problem not the first aider or the Resuscitation Councils' guidelines.

 

 

After the inquest, Mrs Konderak and Sophie's father, John, said the 'shortfall in the level of training and equipment' contributed to their daughter's death. They added: 'We hope the coroner's recommendations will lead to an improvement in lifesaving training and no further lives will be lost.'

I would like to believe that students on our courses would not make the same mistake. The resuscitation council changed the guideline to remove the pulse check a few years ago because bystanders were not starting CPR when they needed to. First Aiders often thought they detected a pulse when one was not present. In our experience pulse checks are very difficult when you are panicking!

Stuart Marshall, Director of Marlin Training says: On our courses we always stress the importance of checking for 'normal breathing'. The girl in this case was exhibiting 'agonal breathing (the last death throws). Agonal breathing is present in up to 40% of pre-hospital cardiac arrests. Agonal breathing can sound like gasping, snorting, gurgling, moaning or laboured breathing. It is NOT 'normal' breathing. For several years now we have recognised the importance of first aiders recognising agonal breathing and have shown  videos of 'agonal gasps' so that our students know that these are not normal breathing and continue CPR. We have also said ; "It's probably best to continue CPR until either you are exhausted, someone else takes over, or the patient kicks you off their chest".

If you want to see agonal breathing watch these two videos and remember not to stop until NORMAL breathing returns.

 

 www.youtube.com/watch