Waingaro Hot Springs' only qualified lifeguard declined to use CPR on a 3-year-old boy because she was wearing dentures and had a sore throat.
Bystanders instead gave CPR, but it was taken over by another pool staff member who had "basic training" in resuscitation.
Evidence was given at the Huntly Coroner's Court yesterday that Aranui Rawiri died on November 13, 2002, at the pools east of Ngaruawahia, having been left unsupervised by both his mother and pool staff.
The qualified lifeguard, Amro Singh, also the owner of the pools, said she had warned the mother of the boy several times to watch the child.
A Water Safety report was commissioned by police at the request of Huntly coroner Bob McDermott after he expressed dissatisfaction with the outcome and findings of the initial Occupational Safety and Health report.
The water safety watchdog found the pool's systems and practices to be short of industry standards, and said Aranui's death would probably have been prevented if he had been adequately supervised.
Report writer and investigator Matt Claridge said ACC Poolsafe standards were voluntary but were being met by 137 public pools out of the 171 nationwide.
Waingaro's response to the emergency was also found to be below industry standards, said Mr Claridge.
Mother Tiana Bobby Rawiri said she took Aranui and his younger brother to the pools, having picked them up from her father's house.
"My children were staying with my father as I was undergoing treatment at the Henry Bennett Centre [a mental health facility] at Waikato Hospital."
During their time at the pools, the trio alternated swimming between the large pool and a nearby smaller hot pool.
Witness Stephen O'Hara, an American visiting at the time, said in a statement that as he left the changing rooms he noticed Ms Rawiri carrying Aranui.
"I said to her, 'Is he all right?' She said 'Yeah, I think he's all right, I found him floating over there.' She didn't seem worried. I could see something was dreadfully wrong."
He took the boy from the mother and said he panicked, as he had not received formal resuscitation training, but began CPR anyway. Another family came up and began helping with CPR.
An attendant was told to call an ambulance and another staff member helped with the CPR.
"The owner came over and said, 'Oh yeah, you're doing well, you're doing it right. I would help but I've got dentures and a throat infection, and I can't help'."
In written evidence, Mr O'Hara's wife criticised Mrs Singh, and said it was reasonable to think she would have taken charge of the situation.
"She [Mrs Singh] also turned to the mother and said, 'I told you to watch those children'."
The O'Haras said bystanders, including themselves, had given Mrs Singh their contact details, but Mrs Singh later told investigating authorities she did not have them.
Later in the hearing a forceful statement was given by Aranui's aunty, Te Puna Moanaroa.
She said Waikato District Council, as lessors of the pools, had a duty to ensure industry standards were met but had sadly failed.
She added that immediately after the death, Water Safety had offered to review the drowning but was turned down by both the police and the pool owners. The officer in charge of the investigation felt the $1500 cost of the review was not the responsibility of police.
"When is monetary value a consideration when a life has been lost, our boy's life at that?"
The coroner reserved his findings.
Lifeguard declined to use CPR on child
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