Teen who drowned at Winnipeg pool 'paid with his life' for changes at city facilities, family says
Review found 'inconsistencies' in emergency response after 14-year-old drowned
A non-functioning radio, a delayed 911 call and an emergency alarm that took several attempts to turn on were some of the challenges that staff faced after an unconscious 14-year-old boy was discovered at the bottom of a city pool last year, an internal review says.
Adam Sereda-Paul was found unconscious in the pool's deep end at the Cindy Klassen Recreation Complex at about 4:38 p.m. on April 1, and later pronounced dead in hospital.
A post-incident analysis by the city's recreation services division, dated Oct. 31, outlines the timeline, circumstances and employee interviews involving Adam's drowning. It was provided to CBC News by Adam's mother, Cindy Paul.
While there were three lifeguards working at the facility when Adam was found unconscious, only one of them was on the pool's deck. The analysis says there is "unclear direction" about how many lifeguards should be on a pool's deck throughout the city's facilities.
The lifeguard who found Adam unconscious in the pool said he did not use his handheld radio after the discovery, and that an emergency button was pressed multiple times before the alarm was activated.
"If I am being honest, I don't remember if my radio was working," the lifeguard is quoted in the analysis. "What I remember is there [was] no one sitting at the side close to the dive tank."
Adam wasn't breathing when he was pulled out of the water, and staff did not find a shockable heart rhythm when they used an automated external defibrillator on him. Lifeguards did multiple rounds of CPR before the Winnipeg Fire Paramedic Service took over care.
The analysis found that front desk staff did not complete their counts of how many people went to the pool on that day.
Staff were also uncertain about procedural differences between adults and children when using an automated external defibrillator, as well as the correct CPR order, the analysis says.
There were "inconsistencies" in the aquatic emergency response that were also noted in the analysis, which recommended the four staff who responded to Adam's drowning receive a developed and personalized retraining plan.
The report also recommends several enhancements to training and procedures at city pools, like ensuring lifeguards test their own radios at the start of each shift, determining how many lifeguards should be on deck for each city pool, and reinforcing emergency responses.
'Obvious' changes: family
The city has since boosted the minimum number of lifeguards that are on deck at Cindy Klassen and similar pools up to two guards at all times, which is above the Manitoba Public Health Act's minimum requirement of one, a spokesperson said in a statement to CBC News.
All safety equipment was tested, and lifeguards were retrained in emergency response procedures such as first aid, CPR and how to use safety equipment. The city says it also hired the Lifesaving Society of Manitoba to examine the city's guarding processes and training.
Adam's family say they're pleased with the changes made by the city, but called them "obvious" procedures that should have already been in place.
"Our son and brother Adam, who had a huge passion for life, paid with his life for the city to realize this," the family's statement said.
"Not one person from the city has even attempted to contact us in any way. They seem to have no problem speaking with the press though. We are beyond devastated, angry and hurt."
Before Adam drowned, staff said the pool was less busy than expected for a holiday, with about 15 to 20 people in the shallow end, according to the partially-redacted analysis.
The teen had arrived at the pool by himself between 3:30 and 3:45 p.m., but told staff that his mother was coming to watch him, the analysis says. He was granted access to the pool's deep end after he completed a swim test around 3:50 p.m.
Adam was seen swimming in both the shallow and middle sections of the pool at about 4 p.m., which is also when lifeguards switched duties.
The teen was the only person in the deep end of the pool, but was seen heading toward the shallow end by staff sometime between 4 and 4:30 p.m., the analysis says. It was the last time staff saw him before he drowned.
Cindy previously told CBC that she'd been watching her son swim from the facility's observation deck, but went to the bathroom at around 4:11 p.m.
At 4:30 p.m., two lifeguards noted that the deep end of the pool was clear as they rotated duties with a third lifeguard — just two or three minutes before Adam drowned, the analysis says.
Video of the pool's observation area on that day was handed over to police, but the city did not keep its own copy and it was eventually overwritten, the city's community services Freedom of Information and Protection of Privacy Act co-ordinator wrote to Cindy.
With files from Josh Crabb