1. [REDACTED], Managing Director, Atlantic Reach Limited

I am Andrew Cox, the Senior Coroner for the coroner area of Cornwall and the Isles of Scilly. 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners  (Investigations) Regulations 2013. 

On 18/9/24, I concluded the inquest into the death of Robin van Caliskan.

A jury found the cause of death as 1a) Drowning.
A jury recorded a conclusion of Accidental death.

On 31/7/23, Robin, who was aged five, came with his family to Atlantic  Reach holiday park in Whitecross, near Newquay for a short holiday. 
Later that afternoon, the family decided to go for a swim in an indoor pool. There were no lifeguards on duty. 

The main pool was described as busy and was close to the stipulated maximum capacity. As it was the main holiday season, the pool users included a number of children. 
For a brief period of time, Robin was not under the direct supervision of  his parents. He was found face down in the main pool and recovered to  the side where resuscitation was attempted. This was unsuccessful and there was recognition of life extinct at 17:55.  

During the course of these inquests, the evidence has revealed matters  giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows.

1) A risk assessment conducted by the company that took account of existing Health & Safety Guidance concluded that it was not  reasonably practicable to use lifeguards except on the relatively  few occasions when large inflatables were permitted in the pool.  
2) While there was felt to be compliance with existing minimum legal  standards, a Health & Safety enforcement officer with Cornwall Council felt this was borderline. She observed that similar sized  companies elsewhere did provide a lifeguarding service. She felt  lessons had not been learned and said that the company should be doing more. 

In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such  action. I was told the company will be reviewing its risk assessment in this regard over the coming weeks in light of the evidence that came out at  inquest to consider whether there are any further steps that it may be appropriate to take. 

You are under a duty to respond to this report within 56 days of the date of this report, namely by 15 November 2024. I, the coroner, may extend  the period. 
Your response must contain details of action taken or proposed to be  taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. 

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 

[REDACTED]
 
I am also under a duty to send the Chief Coroner a copy of your response.  
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 
representations to me, the coroner, at the time of your response, about  the release or the publication of your response by the Chief Coroner.