SINGAPORE: A six-year-old girl, who died in hospital after being found motionless in a swimming pool during a group lesson in 2017, had been left to swim on her own, a coroner's inquiry found on Tuesday (Apr 2).
She had likely encountered difficulty when she was left to swim alone in the middle of the teaching pool, said State Coroner Kamala Ponnampalam.
This went undetected by both the swimming coach and the lifeguards deployed - two of whom left their posts - and she was later discovered in an unresponsive state.
Sherlyn Ler's mother had taken the child to Kallang Basin Swimming Complex for an elementary-level swimming lesson on Dec 20, 2017.
The 1.11m-tall girl, who could not swim independently without swimming aids or support, was with a group of five other students in a teaching pool which was 0.8m to 1m deep, said the coroner.
Her mother sat at a platform near the swimming pool to keep a lookout for her daughter, but was noted to check her phone or speak to other people at intervals, the inquiry found.
SWIM COACH TURNED AWAY TO INSTRUCT ANOTHER STUDENT
After warm-up exercises, swimming coach Matthew Yeo guided Sherlyn to the midway point in the pool with a swimming board before turning away to help another student to the opposite edge of the pool.
Within a few minutes, a group of children found Sherlyn lying motionless in the water and shouted for help.
The coach and a lifeguard took Sherlyn out of the water and conducted cardiopulmonary resuscitation on her before taking her to the hospital, where she was diagnosed with a submersion injury.
She was treated at the hospital for 20 days, but her condition worsened and she died on Jan 9, 2018.
A forensic pathologist determined her cause of death as oxygen deprivation to the brain following near-drowning, with no autopsy evidence of any other medical condition that could have contributed to death.
The inquiry found lapses in the swimming coach's management of his class.
"The class formation was poor. At several points in time, more than one student was out of his line of sight," said the coroner.
"Children in particular need constant supervision around water which cannot be done if the coach is not able to see them. Ideally, the child, especially one who is not an independent swimmer, should be within arm’s reach."
LIFEGUARD IN CHARGE OF TEACHING POOL WAS USING PHONE
The inquiry also found that there were three lifeguards on duty that day at Kallang Basin Swimming Complex.
Firdaus Rajatmarican was at the teaching pool while two others - Law Kum Wah and Kwek Boon Seng - were at the competition pool.
Police investigations found that two lifeguards had left their posts on that day and were observed in closed-circuit television footage to be at an open seating area.
The lifeguard at the teaching pool, Mr Firdaus, was seen looking at his phone at 7.05pm, about 10 minutes before Sherlyn was found unconscious.
He later explained that he had broken the rule forbidding phone use and taken his phone with him so he could monitor his mother at home via an application linked to cameras in his home.
He then walked to a toilet, while another lifeguard Mr Law, who had been asked to take over Mr Firdaus, was seen arranging chairs at an open seating area at 7.09pm.
According to Mr Chng Kiam Ghee, chief lifeguard at the Singapore Sports Council Lifeguard Academy, lifeguards should not carry or use any mobile devices while on duty and are not supposed to leave their points unattended.
Both Mr Firdaus and Mr Law are no longer employed as lifeguards.
According to the evidence of an adult educator at the Lifeguard Academy, the deployment of three lifeguards was satisfactory, but he recommended that a pool guardian be deployed to the wading pool when there are only three lifeguards available.
"Ideally, as there are five lifeguard duty points at Kallang Basin Swimming Complex, the competition pool and the teaching pool should have had two lifeguards each and a third lifeguard assigned to the wading pool," noted the coroner.
She added that the number of lifeguards was only half the equation, with the vigilance of the present lifeguards being of equal, if not more, importance.
"The lifeguard should not be distracted by the use of his personal devices or idle chit chat," said the coroner. "He should never leave his post unguarded. Drowning is known to occur quickly and quietly between 20 to 60 seconds."
The coroner ruled Sherlyn's death as a tragic misadventure, with no basis to suspect foul play, and extended her condolences to the family for their loss.