Kyra Hill unlawfully killed after 'gross breaches in health and safety,' coroner rules

An 11-year-old girl who died at a Datchet water park was unlawfully killed following ‘gross breaches’ in health and safety measures, a coroner has concluded.

Croydon schoolgirl Kyra Hill had been attending a friend’s birthday party at Liquid Leisure on August 6, 2022 when she got into difficulty in the water.

She was playing in a busy designated swimming area known as ‘the beach’, a cordoned-off part of the lake.

A lone 17-year-old lifeguard overseeing the beach saw someone splashing around in a way that suggested they were ‘definitely out of their depth.’

Swimming out to the scene, the lifeguard, Abbi, got to Kyra’s last known position within 10 seconds, but was unable to find her, despite diving under several times.

The inquest heard this was further confused by reports from fellow swimmers that Kyra had left the area.

Abbi radioed for help, but due to the confusion, fellow staff were under the impression they were looking for a missing child.

As such, they searched other parts of the water park, but the place where Abbi had seen Kyra go under was not searched again for another 10 minutes, the inquest heard.

When Abbi did look for Kyra in the water again, it was in the same spot, as she ‘knew instinctively’ it was the right one.

Indeed, when Kyra was eventually found, she was close to the spot where she was last seen by the lifeguard.

The director of Liquid Leisure, Stuart Marston, told the inquest that Kyra’s whereabouts were unknown for about 20 minutes.

He said there were 30 lifeguards looking for her and 20 people diving with goggles. The attractions at the park were closed down, and Mr Marston described it as a ‘chaotic scene’ of 'complete panic and confusion'.

Mr Marston called emergency services – and it took professional divers ‘some time’ to find Kyra.

When she was found, she was taken to Wexham Park Hospital, where she was pronounced dead.

The inquest concludes

A four-day inquest concluded today (May 20) in a packed coroner’s court filled with Kyra’s immediate and extended family.

The coroner was asked by Kyra’s family to consider whether what happened amounted to either corporate manslaughter or gross negligence manslaughter (by Mr Marston specifically).

Heidi Connor, senior coroner for Berkshire, said that in her view the threshold for gross negligence manslaughter had not been reached.

This was because Liquid Leisure was a large organisation, where it was expected that Mr Marston would delegate various roles – including health and safety oversight.

Rather, problems at Liquid Leisure were a function of the place as a whole, Mrs Connor concluded.

There were breaches in duty of care while Kyra was in the water.

Though there was CCTV focused on the place where Kyra went under, this was not reviewed to check Kyra’s whereabouts while staff were searching for her.

During the search, staff were ‘slow to clear the area’ and ‘uncoordinated,’ Mrs Connor added.

Moreover, there were further breaches before Kyra arrived at the park; there was a ‘plain’ absence of an emergency plan and appropriate warning signs, Mrs Connor determined.

One major factor in the decision was the presence of signs warning of shallow water, but none for how deep the water could get (up to 4.67m).

Mrs Connor described these as ‘falsely reassuring signs’.

She said it was ‘reasonable’ for a parent or carer to assume from these that the water was shallow all the way across the swimming area.

During the inquest, Mr Marston repeatedly stressed that there is no national legislation binding water parks to various decisions – including what signage or other warnings should be in place.

Mrs Connor said she inferred from Mr Marston’s words that he thought parents should have guessed the swimming area might be deep, without needing to be specifically warned, since it was part of a lake.

But Mrs Connor felt this was unclear as the area was demarcated for young children.

She also could not accept that an absence of national legislation could absolve Liquid Leisure of responsibility, saying this was ‘too simplistic’.

"It simply cannot be the case that, if there are no written down national or international standards, then there can be no breach of duty," Mrs Connor said.

“There has not been just a single error here – there have been numerous serious breaches.”

The decision

Though inquests are not the same as criminal courts, a coroner can return a finding of unlawful killing – which Mrs Connor did.

Among her ‘serious concerns’, Mrs Connor noted the misleading/absent signage, and the fact that parents were not advised that the ratio of adults to children in the water should be one adult for every four children.

Mrs Connor added that there was no emergency plan, risk assessment or control measures to take account of these risks.

As such, Kyra Hill 'was unlawfully killed following gross breaches in health and safety measures at the park which contributed to her death’, Mrs Connor concluded.

She said could not say for sure whether, if Kyra had been found any quicker, she would still be alive today.

But Mrs Connor did suggest that better processes for emergency drills could have helped prepare Liquid Leisure for events like this.

These drills could have covered such vital topics as when to use CCTV, where to conduct searches and when to call 999, she said.

Kyra in memoriam

Speaking before the coroner’s conclusion, Kyra’s father, Leonard Hill, read out a ‘pen portrait’ from the family about Kyra and her life.

They described her as a determined and accomplished girl with an ‘unstoppable drive’ who belonged to five school clubs and held a great love for the outdoors.

She had a strong moral compass, always wanting to protect and help others where she could – and was a ‘free spirit’ with an adventurous imagination and a ‘vision for fashion.’

Kyra had an ‘infectious laugh’ and ‘captivated hearts effortlessly’ with her smile. She loved sports and dreamed of becoming a professional football player.

She was ‘never shy to show her love’ and was close with her siblings, bringing out a ‘maternal instinct beyond her years’.

“She was a beautiful beacon of light to all those fortunate enough to know her,” Mr Hill said.

“Kyra brought happiness to our hearts every single day, and still does.

“We’re privileged to have so many special memories of her.

“Although she may no longer walk this earth, she will be forever in our hearts.”