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Ireland : Young girl (9) taken from pool died due to heart condition - inquest

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Ireland : Young girl (9) taken from pool died due to heart condition - inquest

Post by Waterbaby »

../.

"Staff began chest compressions and brought the defibrillator but could not use it because the battery was low, the court heard. Emergency services were called at 7.12pm and arrived at 7.19pm. Responding to questions about directions, Dublin Fire Brigade Station Officer Dominic Taaffe told the coroner the Eircode system is not compatible with Dublin Fire Brigade's satnavs and staff have to use their own personal mobile phones to access an Eircode."

https://www.independent.ie/irish-news/c ... 85724.html

https://www.eircode.ie/what-is-eircode

https://www.gosh.nhs.uk/conditions-and- ... ogy-fallot

RIP little lass :heart:

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Re: Ireland : Young girl (9) taken from pool died due to heart condition - inquest

Post by bernicarey »

So Eire is a bit behind the curve in terms of having postal address coding, but they have gone as far as individual properties.
When I lived in the USA, they thought the UK was advanced because a ZIP Code in the USA is quite literally the Post office that handles that address, so the equivalent of only the first part of a UK Postcode.

It seems ridiculous that the Dublin Fire Service can't cope with the Eircodes; if the Codes have been in use for over 3 years, you'd think they could have got a software update by now.

As to AED batteries being low... :shock: What the heck! That needs serious attention. Depending on Make and Model, they should know what they need to do about batteries:
Returning a narrative verdict, the coroner recommended that facilities with defibrillators have a system of ensuring the equipment is functioning. The inquest heard that the defibrillator at the Tallaght Schools Complex is being checked daily since the child’s death.
Checking daily?
And how much are they draining batteries by checking daily?
Checking in accordance with manufacturer's instructions would be a good thing to do.
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Re: Ireland : Young girl (9) taken from pool died due to heart condition - inquest

Post by ssmith65 »

Our defib is rented and part of the rental contract include a quarterly visit to check and ensure the battery its charged and that the pads are in date. Our model actually has a clear window with a green/red display so you can see if its charged.
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Re: Ireland : Young girl (9) taken from pool died due to heart condition - inquest

Post by stephen1974 »

bernicarey wrote: Thu Mar 07, 2019 9:41 am
Checking daily?
And how much are they draining batteries by checking daily?
Checking in accordance with manufacturer's instructions would be a good thing to do.
Sorry but you check daily. Absolutely 100% no if ands or buts. Why? because of situations like this. You cant check once a week, have it ok on a monday, go dead on a wednesday and be needed on a friday. The same goes for ALL emergency systems in a pool area. You check every single day before you let anyone in the pool. Draining the batteries is irrelevant as a quick check doesnt drain the battery any significant amount, you can do it for months and months and not run the battery down. You dont turn the defib on and run through things, you press a button and a charge level shows up, thats it. Once a month you can go through more complete checks.

If that had been properly checked in the morning they would have caught the issue and changed the battery or put it on charge and made all the lifeguards aware this was the case.

I guarantee this device had not been properly checked in a long time. There are too many things managers are expected to do in opening up a leisure center and they are generally given 15 to 30 minutes to do it. You have all the fire doors and escape rooms to check, all the poolside alarms and disabled toilet alarms to check, the plant room checks, the pool water tests to complete and so on and so on, including checking the defib is working. Most places do not allow these checks to be delegated down to other staff, so the manager is expected to do it, and thats just the checks listed, there will be a bunch of other stuff to do as well. In no mote than 30 minutes. So things get missed. Assumptions get made and a defib comes low on the list of priorities due to the assumption it wont be needed. In 16 years on managing leisure facilities i've seen them used once and one time one should have been used but they were not common place back then so we didnt have one.

The questions for me would be:
Why was it not being checked daily already? what did the RA and SOW say?
Why did it require the parent spotting the girl and going in for her? What were the teacher to pupil ratios? Where were the teahers? in or out of the pool? Why did the life guards not spot her first?

7 minutes to get to her with a dodgy sat nav. Thats pretty damn good going. How much time realitically was lost getting to her? not enough to make a difference i bet. That doesnt excuse the nav system issue, but I dont think this was a contributing factor in her death.
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Re: Ireland : Young girl (9) taken from pool died due to heart condition - inquest

Post by bernicarey »

stephen1974 wrote: Tue Mar 12, 2019 3:26 am

Sorry but you check daily. Absolutely 100% no if ands or buts. Why? because of situations like this. You cant check once a week, have it ok on a monday, go dead on a wednesday and be needed on a friday. The same goes for ALL emergency systems in a pool area. You check every single day before you let anyone in the pool. Draining the batteries is irrelevant as a quick check doesnt drain the battery any significant amount, you can do it for months and months and not run the battery down. You dont turn the defib on and run through things, you press a button and a charge level shows up, thats it. Once a month you can go through more complete checks.
Can't agree.
You check in accordance with manufacturer's instructions. They are the authority on their equipment.

Whatever the check is, check in accordance with the manual.

Do you really think that each and every Public Access AED across the Country is checked daily! If they were unreliable enough to require daily checking they wouldn't be installed in cabinets up and down the country.

Even the Resus Council say "All currently available AEDs perform regular self-checks and if a problem is detected it will be indicated...... Those owning an AED should have a process in place for it to be checked regularly and frequently (ideally daily) for such a warning...."

So checking daily is an 'ideal' when practicable.
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Re: Ireland : Young girl (9) taken from pool died due to heart condition - inquest

Post by stephen1974 »

It neds to be checked daily (or whenever the facility you are in is in use). You must physicaly check that it is where it should be, that all its components are present, that it is charged and that it is not showing a fault. It is completely unexceptable to to say its ok to do it on a Monday, have it fail on a wednesday and be needed for a Friday.

Have a look at what people like the Red Cross, St Johns, British Heart Foundation, Resuscitation Council UK say on it, in fact, this is what the later has to say.

"All currently available AEDs perform regular self-checks and if a problem is detected it will be indicated. In most cases they show this by a warning sign or light visible on the front of the machine. Those owning an AED should have a process in place for it to be checked regularly and frequently (ideally daily) for such a warning, and for appropriate action to be taken when necessary."

Yes, all AED's perform a weekly self test. The issue is how do you know there is a problem unless you check? You have to physically check, and you have to do it every day. Those ones in cabinets are generally in low risk areas but all will have someone responsible for checking them.

In a high risk environment like a swimming pool there is no practical reason NOT to do a daily check.
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Re: Ireland : Young girl (9) taken from pool died due to heart condition - inquest

Post by bernicarey »

Stephen,
You have quoted back to me the very same quote I already gave....


So you believe that
Those ones in cabinets are generally in low risk areas but all will have someone responsible for checking them.
And yet your earlier comment was
In 16 years on managing leisure facilities i've seen them used once and one time one should have been used but they were not common place back then so we didnt have one.
So you've personal knowledge of use in a Leisure facility on an average of 1 in 8 years, and yet you claim PADs are in 'low risk areas'. I'd call 1 day in 2,920 pretty low risk especially when the numbers of people per day are factored in too.


But all that's irrelevant when it comes down to the fact that my original statement clearly concluded with
Checking in accordance with manufacturer's instructions would be a good thing to do.
Your statement
It is completely unexceptable to to say its ok to do it on a Monday, have it fail on a wednesday and be needed for a Friday.
is like saying you keep testing the light bulb, because you need to know it will work when you need it.
What if I Check it at 09:00, it fails at 13:00 and I need it at 16:30?

Any checking of an item is relevant to it's reliability and MTBF (mean time between failures) as determined by the manufacturer; you have to draw a line somewhere based on probability, backed up by data.

And I'll just leave it there....
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