Coroner calls for tougher safety rules after woman drowns at retirement home

An elderly woman who was unable to get out of a pool at the retirement home she’d recently moved into was found floating face down several hours after going for a swim.

Now a coroner has taken aim at the need to improve safety around swimming pools at retirement homes, after her second inquiry into the drowning of an elderly person at a retirement village that provided a pool.

A further investigation is also underway into the death of a third elderly person who was found in a swimming pool at a Christchurch retirement village in May last year.

On Boxing Day in 2019, an 86-year-old woman, was found floating in the pool at Eastcliffe Retirement Village in Auckland’s Ōrākei where she’d lived for only two months.

Coroner Tania Tetitaha’s investigation into the woman’s death explored a number of factors including her health at the time and gaps in the rest home’s processes which have since been improved.

The woman had been living in one of the village’s apartments and was said to be struggling with grief over the death of her husband 18 months earlier.

Three months before she died she was prescribed medication to help with anxiety and later suffered a fall at home that required her to be hospitalised.

On admission, she was found to have hyponatraemia (low serum sodium) which is associated with confusion and an increased risk of falls. It was a factor explored in the death, but challenges with the sodium testing process meant it was inconclusive, Tetitaha said.

Before the drowning tragedy, the woman had celebrated Christmas with her family, who raised concerns about her emotional wellbeing when she was taken back to Eastcliffe the next day.

Shortly after returning, she asked the receptionist to show her the pool, which she had never used before but was considered physically capable of using.

The CCTV video feed from the pool area was linked to the reception computer, but because the feed slowed down the computer the receptionist took the video off security mode and minimised it to allow her to do her work.

This meant the pool area was not being actively monitored when residents were using it, Tetitaha said.

A copy of CCTV footage showed the woman entering the unlocked pool area at 1.30pm.

Three minutes later she was in the pool, submerged up to her neck and holding onto a handrail at the bottom of the pool steps. She then tried twice to get out before she let go of the handrail.

By 1.41pm she was seen on the footage floating face down in the pool but she was not discovered until later that evening by the head housekeeper who had been asked to look for her. Family had tried reaching her directly by phone around dinner time and then phoned the rest home when she could not be reached.

Tetitaha said there were similarities between the two retirement home drownings she had investigated, including that the pools were not being monitored or supervised, the pool barrier door was not self-closing nor had audible alarms if it remained open, neither restricted entry to the pool by residents who were medically unsuitable or unable to swim unless supervised, and training in water safety was not provided to staff or residents.

Eastcliffe confirmed to the coroner that the pool complied with all legislative and regulatory requirements and that it had since taken a number of steps to improve safety around its use. This included a permanent video camera monitor at reception, which displayed real-time footage of the pool to receptionists and the night security guard.

The coroner also sought input from the Ministry of Health, which sets standards for the delivery of health services in rest homes, and Auckland Council, which sets rules around swimming pools under the Building Act that are aimed at preventing young children from gaining unauthorised access to pools.

Tetitaha said it would also be useful to have a rule that prevented access by those unable to swim unsupervised for any other reason, but as it appeared little could be done under the Building Act to prevent such deaths, she was unable to make a further recommendation.

She said the risk of drowning among adults aged 65 and over had increased and this age group now made up 17 per cent of water-related fatalities in New Zealand.

One reason was the inaccurate assessment of their water competency levels.

Eastcliffe Retirement Village manager Merrin Gemmell told NZME that residents’ safety remained a priority.

“We want to express our deepest condolences to (the woman’s) whānau and those who were impacted by (her) loss, including our residents and members of our team. Our thoughts continue to be with them,” Gemmell said.

-By Tracy Neal
Open Justice multimedia journalist