Teen’s death at city pool sparked policy, training changes for lifeguards

Hey there, time traveller!
This article was published 21/02/2025 (199 days ago), so information in it may no longer be current.

A series of failings — a delay in calling 911, an emergency alarm that took several attempts to activate and a radio that wasn’t in working order — may have played a role in the drowning of a teenager in a City of Winnipeg pool last spring.

An internal post-incident analysis, obtained by the Free Press via a freedom-of-information request, details the response to the April 1, 2024 emergency at Cindy Klassen Recreation Complex — and made recommendations to improve safety at the facility and other city pools.

The 14-year-old Churchill High School student, in critical condition when he was rushed to hospital by Winnipeg Fire Paramedic Service personnel late that Easter Monday afternoon, was later pronounced dead.

The death sparked change at city pools, with the minimum number of lifeguards increased and training beefed up, among policy reviews.

“We can’t let this young boy who’s died, we can’t let him die without learning from what mistakes we made — we have to look at what we need to be doing to protect families, kids who are swimming,” said Coun. Cindy Gilroy, who represents the Daniel McIntyre ward, where the pool is located.

One lifeguard was on duty on the pool deck at the time; two others were working elsewhere in the Sargent Avenue facility, the June 20 report prepared by city staff stated.

Staff didn’t know the 14-year-old boy was swimming in the deep end of the pool until he was discovered unresponsive in the water, the report indicated.

The report, which was redacted in parts, outlined several emergency response issues including a delay in calling 911, issues with the pool’s emergency alarm and the handheld radio on the deck, among uncertainties about policy.

Although some details of the first-aid response of staff are redacted, there was confusion about cardiopulmonary resuscitation protocols and uncertainty about differences between defibrillator procedures for adults and children, the report indicated.

The report also found that front-desk staff had not counted the number of patrons going to the pool. It recommended the city formalize procedures for front-desk staff and that regular review of the number of swimmers be recorded on a time schedule.

The report’s broader recommendations included enhanced training across the board and an examination of lifeguard policies at all city pools, much of which the city said it has done.

“We can’t let this young boy who’s died, we can’t let him die without learning from what mistakes we made — we have to look at what we need to be doing to protect families, kids who are swimming.”–Coun. Cindy Gilroy (Daniel McIntyre)

City spokesman Adam Campbell said in October that following the post-incident analysis, officials increased the minimum number of lifeguards on deck at the pool and similar facilities to two at all times, exceeding the provincial legislation’s minimum of one-to-30 swimmers.

The city also retrained lifeguards in emergency-response procedures, including first aid, CPR and use of safety equipment. All safety equipment was tested to ensure it was in proper working order.

The report recommended a personalized re-training plan for the four guards who responded to the incident.

Campbell said the city hired the Lifesaving Society Manitoba to review and provide any improvements to lifeguarding processes and training.

Another city spokesman declined further comment this week.

Gilroy had not been aware of the internal analysis or the recommendations within it until contacted Friday by the Free Press.

“This needs to be very public — there was somebody who died and I think the family and friends all need to understand that the city is taking this very seriously and putting provisions in place and learning from this tragic event,” said Gilroy.

“My words can’t express how I feel for the family and how that must feel, when you’re taking a child out for swimming — you don’t expect this to happen.”

She said she was glad to learn the city put provisions in place following the tragedy, but added it should be done on an ongoing basis by monitoring policies and keeping staff informed.

The post-incident process included interviews with eight city employees, including lifeguards and other recreation staff who were working at the time, and an administrative co-ordinator who was called to the pool after the incident.

The report said as two lifeguards did a staff rotation at about 4:30 p.m., they “both (clarified) that the deep end was still clear and not in use,” so just the one guard who was reporting for duty went on the pool deck.

That was in line with legislation that dictates one lifeguard per 30 swimmers in a pool at a time — about the number in the water that day.

The lifeguard who came on duty walked over toward the deep-end tank on the north side of the pool deck “just to double-check,” they told city officials. That is when the guard appears to have discovered the unresponsive teen, although that portion of the document is redacted.

That lifeguard rushed to the elevated chair nearby and hit the attached emergency alarm button multiple times before it activated at about 4:38 p.m., and then “waited for backup to arrive on the pool deck.”

“If I am being honest, I don’t remember if my radio was working,” the lifeguard told officials, the report said. “What I remember is there is no one sitting at the side close to the dive tank. I tried to stay as close to the patron as possible.”

The lifeguard said there were no bystanders available to assist.

“I needed backup … nobody would know where I was, especially with no radio.”

Another guard, responding to the alarm, arrived and jumped into the water. The specifics of the attempted rescue are redacted from the document.

A third guard then entered the deck and cleared the remaining swimmers from the pool. Staff appears to have begun first aid, including CPR, while waiting for emergency personnel, but further details are redacted from the document. Another staffer then radioed the front desk to call 911, the report said.

WFPS, called at about 4:39 p.m., arrived at approximately 4:50 p.m. and took over from the lifeguards.

The complex was shut down and police interviewed a number of employees, before forensics investigators documented the scene. When they were done, city employees cleaned the area, wrote incident reports and left by 8:30 p.m., the incident summary said.

erik.pindera@freepress.mb.ca