The jury of a coroner's inquest into the drowning of a Chinese student in Saint John is calling for province-wide safety standards at all public pools and increased minimum training for paramedics.
Yifan (Jason) Wang, 17, died in hospital on Sept. 20, 2011, two days after being pulled unresponsive from the pool at the Canada Games Aquatic Centre.
After hearing three days of testimony from nearly two dozen witnesses, the jury made nine recommendations on Friday, aimed at improving pool safety in Saint John and across the province.
Karen Irwin, general manager of the Aquatic Centre, said some of the recommendations are already standard practice, such as having portable phones at key locations and having a 911 call script checklist to help staff collect and relay information to emergency services.
The pool has also implemented some changes since Wang's death, such as adding an extra lifeguard to the competition pool during open swims.
"There are some that we're going to have to take back and review and make a plan, develop a plan to implement them," Irwin said without elaborating.
Chief coroner Greg Forestell said the recommendations are not binding, but they will be published in his annual report and they will be tabled in the legislature.
The relevant parties and government agencies are expected to respond within six months, he said.
Forestell believes the inquest served its purpose in giving the community a better understanding of what happened at a public pool that is still being used by citizens.
"We certainly have dispelled some rumours," he said. "I think it's important to air the facts."
"There was a certain amount of unknowing about what happened. And I think we still don't know exactly what happened during that three minutes from the last time he was seen til the time he was pulled from the pool."
Family still considering lawsuit
The inquest heard that Wang, who had recently moved to Saint John, went down the three-metre slide into the deep end during a public swim at about 3:18 p.m.
He re-surfaced and appeared to float with the flow of the water for about three minutes before a lifeguard spotted him and blew the whistle.
The pathologist who conducted the autopsy concluded the cause of death was drowning. Marek Godlewski testified his examination of Wang found no abnormalities — no drugs in his system, no signs of broken bones or trauma, no problems with his heart or lungs.
Wang's parents are still considering a lawsuit, said Laura Wentzell, an articling student from Gilbert McGloan Gillis who attended the inquest.
"Our role here was to collect information and data and the facts and to essentially bring that back to the family and they can decide how they want to proceed and then from there we may decide to initiate litigation," she said.
Wentzell expects a decision to be made soon.
The jury's recommendations include:
- Accept all eight recommendations as presented by the LifeSaving Society of Canada, which include having lifeguards stationed at specific pieces of equipment, such as the waterslide and Tarzan swing.
- Additional lighting to be installed in the deep end area to ensure adequate visibility of the bottom of the competition pool.
- Establish a New Brunswick Aquatic Association to publish standard safety guidelines for public aquatic facilities and pool owner/operators.
- Install portable phones at key locations, which may include lifeguard posts and emergency stations.
- Use spine boards in all "major accidents," as defined by the Canada Games Aquatic Centre.
- Add an additional lifeguard to the shallow end of the pool.
- Equip lifeguards with fanny packs filled with first aid tools, such as gloves and masks.
- Play a pre-recorded announcement of pool safety instructions in strategic areas at strategic times.
- New Brunswick paramedics should be required to have a minimum of advanced paramedic training, instead of primary care paramedic training.