Pool drowning case

The following is my preliminary report in a typical pool drowning incident. In developing this preliminary report I reviewed information from police, medical and investigative files.

1. The victim,  CD, was a 14 year old, black male, 74 inches tall, weighing 215 pounds. According to Los AngelesPolice Dept. records, he died from drowning 6/04, after submerging in and being recovered from the swimming pool at the Quality Hotel,Los Angeles International Airport.

2. The victim had arrived in Los Angeles from St. Louis,MO on the day of his drowning as a member of the youth group from a church in St. Louis,MO. The group’s youth pastor was the chaperone. According to his mother, although the victim was “very smart,” had been in several pools and had been shown how to swim, he was in fact a non-swimmer.

3. Per the police report the youth pastor and his wife brought eight church youth to California for a convention. After checking into the hotel and eating at McDonald’s the youngsters expressed an interest in swimming. The pastor and his wife [Mr. & Mrs. J.] took the youth to the pool. A few minutes after reaching the pool, Mrs. J. left to go to the restroom. She specifically told Mr. J. not to leave the kids alone. However, Mr. J. decided to ask a question at the front desk. He states he was gone for two minutes. Upon his return he saw a rescuer diving into the pool. Subsequently, he helped pull CD from the pool. (Note that CD’s mother has indicated that she had told Mr. J. that CD could not swim and that he was to remain in the shallow end of the pool. Also note that the California Code of Regulations (CCR), Title 22, Chapter 20, paragraph 65539 (c) requires signage at unguarded pools stating: “Children Under the Age of 14 Should Not Use Pool Without an Adult In Attendance.” Although CD was fourteen, several other children in the group were younger.)

4. Mr. J. reported to the police that several youths in the group said they had seen CD walk slowly to the middle of the pool from the shallow end and then quasi-dive into the deep end. CD’s thirteen year old sister, Ch, stated that he had asked her  if she could teach him to swim. She then observed him go towards the deep end of the pool, struggle, submerge and remain underwater for two minutes before being recovered. As CPR was being attempted Ch said her brother was vomiting both food and water.

5. CD’s seventeen year old brother Ic stated that he saw CD enter the shallow end of the pool and move toward the deep end. He believed that CD was able to swim due to CD’s apparently swimming from the shallow to deep end. He observed CD vomit and foaming from his mouth in the pool. Ic grabbed the (rescue) pole and attempted to place it in the pool for CD to grab. However, he was too late.

6. Au was a guest on the pool deck at the deep end of the pool. She observed the decedent walk backward from the shallow end to the middle, then disappear underwater. At the time of the incident she was a licensed (certified) lifeguard. CD did not appear to be in distress, but then began vomiting in the pool. Knowing something was wrong she entered the pool and pulled CD from the bottom. She and another female guest attempted to initiate CPR, but were unable to administer it due to CD’s vomiting. In the police report a note is made to the effect that in the hospital when the patient was intubated the tube backed up with thick, brown fluid secretions.

7. Sa was another guest at the hotel who noticed CD walk to the middle of the pool and begin flailing his arms. After he sank and rescue was initiated by Ms. Au, Ms. Sa assisted in pulling CD from the water, then joined Sa in performing CPR. CD kept vomiting, so they turned him on his side and gave him a sharp blow to his back, however he kept vomiting, nullifying their CPR attempts. Shortly thereafter paramedics arrived.

8. California pool regulations require standard safety equipment and signage poolside. There is no requirement for a mid-pool buoy line, although there was a required black tile line on the bottom indicating the beginning of the slope into the deep end. A spokesman from the Los Angeles Health Department said that the requirement for a buoy line had been removed a number of years ago and that it would be difficult to find the date of the change in existing laws and codes.

9. Notification/arrival of EMS was timely, with CPR being provided by qualified personnel prior to paramedic’s arrival.

10. It would appear that the drowning was caused primarily by:

a. Lack of direct adult supervision by Mr. J., abetted by;

b. Vomiting/inability to clear the airway for CPR/ intubation related to;

c. Eating in close proximity to time of water entry, which again relates to improper supervision.

11. A mid-pool buoy line marks the beginning of the slope into the deep end as well as providing a barrier/assistance point for someone unintentionally entering deep water. If in fact CD intended to enter the deep end he could have easily ducked under the line or jumped in from the side. The presence or non-presence of the line in this instance has no bearing on causation. Also, CD is presumed to have known about the danger of entering deep water as well as where the deep water was located, based on his having been in other pools, and his mother’s injunctions to not go out of the shallow end. His mother additionally related that CD was a “very smart” boy. He should therefore have had no difficulty visualizing and understanding pool depth markings found on both the deck and sides of the pool along with the marker strip on the bottom.

As is my standard statement in such cases, “This concludes my preliminary report. I reserve the right to supplement this report based on further discovery and/or evidence. My qualifications are set forth in my attached CV. My opinions are stated to a reasonable degree of probability and reflect my training, experience, education and understanding of the standards and science of aquatic safety.”


David S. Smith, Ph.D.

Commander, USCG (RET)






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