Coroner's report :
Seated position is dangerous for babies
After investigation into the death of a two-month old baby, the Quebec Coroner's office is advising that babies should never be left to sleep in their car seats because of the dangers of asphyxiation. Babies should ALWAYS sleep in their beds.
In french only
Rapport d'investigation du coroner Jacques Robinson - Les dangers de faire dormir un bebe en position assise
Coroner's diving board report
August 3, 2006
Conclusions from total report:
It is an accidental death which could have been avoided.
It is a highly worrisome death, since it can reoccur if the status quo remains.
Safety recommendations include:
To the Ministère du Travail:
- Modify Règlement sur la sécurité dans les bains publics (S-3, r.3) so that any restoration, modification or installation of 3-metre diving board or water slide also provides for an access to the diving board of the water slide via a landing-equipped staircase.
- It is also recommended that Article 14 of the abovementioned regulation be amended in order to specify that the landing guardrail be solid and opening-free in order to keep children from falling 3-metres by passing under the rail. Since supervisors must maintain visual contact with diving board users, the use of plexiglass is recommended or bars no more than 10 cm apart.
To managers of public pools, members of the Union des municipalités du Québec, the Fédération des municipalités du Québec, or the Fédération des commissions scolaires du Québec.
- Where possible, provide for the installation of a staircase with a landing, instead of a ladder, to climb up to 3-metre diving boards.
- Installation of plexiglass (or other clear material) panels to cover the opening beneath diving board guardrails.
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Should they choose not to install a staircase, the following changes should be made to existing ladders:
- Install shock-absorbing flooring to reduce the impact on the head in case of a fall. The flooring should abide by CAN/CSA-Z614-03 standard or F-1292-04 American Society for Testing and Materials Standards regarding impact absorption. To the Association des responsables aquatiques du Québec (ARAQ) : Provide recommendations for solutions offered by Québec manufacturers with respect to flooring.
- Shock-absorbing flooring may reduce the risk of head injury, however it will not reduce the risk of cervical spinal cord injuries. It is therefore not equivalent to installing a staircase with landing, but instead is a palliative solution in cases where installing a staircases poses major technical difficulties. In all cases, shock-absorbing flooring should be accompanied by other changes higher up in the air:
- Make the ladder angle less vertical.
- Install non-stop handrails between the ladder and the guardrail frames, with a diameter no more than 4 cm to allow a good grasp for tiny hands.
- Install non-skid steps than can be changed on a periodic basis when the material starts to wear and becomes less efficient.
- Usage of pictograms to guide children and remind them of the safest way to use the ladder.
- Swinging gates should be locked in order to restrict access to the diving board unless it being is used for competition or by an acknowledged diving club.
- Diving boards should be safely stored away for winter.
If either option is not chosen:
- Restrict use of diving boards to children at least 12 years of age and measuring at least 1.35 metres in height.
For the current season:
- Should not hesitate to restrict the use of diving boards, particularly during busy periods.
To the Société de sauvetage du Québec :
- That it make 2006 or 2007 a year for the prevention of diving board accidents by sensitizing all its lifeguards so that first, they systematically remind the users of the safety rules and secondly, that they forward their recommendations on improvements to equipment that could lead to increased safety and lower injury hazards.
- That it evaluate the pertinence of involving its members by distributing a checklist to compile information on the characteristics of diving boards in Québec.
The Société de Sauvetage du Québec and Plongeon Québec :
- That they participate and actively contribute in the development of new guidelines and standards, owing to their acknowledged expertise.
To the Société canadienne de la Croix-Rouge:
- That it reinforces the safety elements around the pool in its training curriculum on major swimming concepts. In order to ensure some consistency, it should manage enough room in its manual Swimming and aquatic safety to review the wise diver's ABC.
Coroner's Recommendations