An inquest into the death of a student who drowned in a swimming pool found leisure centre management “failed in its duty” to identify, assess and control risks.
Tan Li, 19, who could not swim, drowned in the shallow end of Southgate Leisure Centre, in Winchmore Hill Road, between 3.20pm and 3.45pm on July 3, 2007.
An inquest held at North London Coroner's Court, in Wood Street, Barnet, found there was “insufficient pool supervision” at the pool during the time of the Southgate teenager’s death.
The court heard that one lifeguard and a duty pool manager were in conversation while sat on a ledge by the pool’s sauna while the Southgate College student drowned.
The inquest, which opened on July 4, 2007, and closed on Thursday, October 4, this year, found the staff’s actions on the day were “contrary to normal operating procedures".
No clear evidence was presented to show the teenager’s activities in the pool before he was discovered under water.
The court heard two moveable lifeguard high chairs were positioned on the corners of the pool instead of being each end.
A chair fixed in the centre of the poolside was also not used, which the court heard “seriously hampered” the lifeguards’ ability to effectively monitor the pool area.
Although CPR started straight away once Mr Li was removed from the pool, the correct order of resuscitation was not applied.
First aid equipment was also not easily available and breathing tubes were missing from face masks. The court heard the combination of failures “seriously hampered lifesaving”.
Resuscitation had already finished when a paramedic arrived at the poolside, and although Mr Li was found in the recovery position, the court heard training had “not been taken seriously enough by the management”.
The court heard: “From the evidence heard we conclude that the leisure centre management failed in its duty to ensure risks are adequately identified, assessed and controlled. This leading to insufficient pool supervision and the failures noted above.”
The student had moved to Enfield from China three years before his death.
His father, who would not give his first name, spoke to the Enfield Independent at the time of his son's death.
Mr Li, who spoke through a translator, said: "How could this kind of tragedy happen to Tan? We just can't believe it.
"He wanted to have a wonderful family, learn about computers and had lots of plans for the future. Sadly he's lost his life and leaves his family behind here."
When Mr Li died, the Enfield Independent understands the leisure centre was managed by Enfield Leisure Centres Ltd, which ran the borough's leisure centres on behalf of Enfield Borough Council.
However, it is now run on behalf of the council by sports and leisure organisation Fusion.
The council did not wish to comment.
The Enfield Independent is waiting for a comment from Southgate Leisure Centre.