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Two-year-old Ranger Hetaraka was found floating face down in a pool at the Napier Aquatic Centre in late 2020.
The toddler died four days after the incident in Starship Hospital.
WorkSafe did not lay charges in relation to the drowning.
Pool staff had acted appropriately and Ranger’s death would have been prevented with parental supervision, Coroner Erin Woolley ruled.
A coroner says parental supervision could have prevented a toddler’s death at a Napier public pool - and that people must remember lifeguards are not babysitters.
Coroner Erin Woolley laid out the facts of 2-year-old Ranger Hetaraka’s death in a ruling released today.
Ranger was found floating face down at the Napier Aquatic Centre pool on December 5, 2020.
He was taken from the pool to Hawkes Bay Hospital in Hastings where he was treated before being flown to Auckland’s Starship in critical condition.
The toddler was transferred to the Paediatric Intensive Care unit.
Ranger did not recover and died in Starship Hospital four days after the incident when the decision was made to withdraw breathing support.
Two-year-old Ranger Hetaraka was found floating face down in a pool at the Napier Aquatic Centre in late 2020.
Following the child’s death, the case was initially investigated as suspicious by the police.
A WorkSafe spokesman said an investigation into the matter was completed in mid-August of 2021 and no charges would be laid against any party involved.
The coroner’s report said the toddler and his family arrived at the pools to attend an outdoor pool birthday party at around midday.
During the party, Ranger and another child went to the children’s pool area inside the facility with an older member of the family.
Woolley said CCTV footage showed the children playing and the older member leaving them unsupervised, as a lifeguard watched the children.
A lifeguard stopped Ranger two times when he left the toddler pool and tried to run to the learners’ pool ladder.
A lifeguard yelled, asking who was with the 2-year-old, and a family member then carried the toddler into the learner’s pool.
A CCTV camera was somewhat obscured by a pillar, although Ranger was still visibly seen being put back into the toddler’s pool a short time later.
After a few seconds, what appeared to be Ranger’s head could be seen in the learners’ pool after the toddler had walked there from the toddler pool.
“Ranger’s head appears to bob above and below the water’s surface. During this time there were around 15 people coming and going from the children’s pools and several more walking around the perimeter of the pool area,” Woolley said.
There were about seven people, both adults and children near the toddler when he was having difficulty keeping his head above the water.
The death of a toddler in a public swimming pool in Napier has led a coroner to stress that lifeguards are not babysitters. Photo / NZME
While the toddler was seen struggling on CCTV, the lifeguard was preoccupied with people in another pool.
About two minutes later a different lifeguard said “grab the baby” after seeing the toddler face down.
A man near Ranger in the pool took the child out of the water and a lifeguard started performing CPR.
A woman at the pool helped to clear the child’s airways at the scene before ambulance staff took over.
The Napier City Council undertook an independent investigation following the tragedy.
“The review included viewing the CCTV footage from the pool area, speaking to the pool staff members who were on duty on 5 December 2020, considering the relevant Napier Aquatic Centre Operating Procedures, lifeguard training and the physical environment of the pool area, including the layout of the pools and the positioning of the CCTV cameras,” Woolley said.
The lifeguards were found to all be positioned in the appropriate locations and the CCTV footage showed they were actively carrying out their duties.
The review also found that a lifeguard had spoken to one of the family members about the need to supervise Ranger in the water twice.
“The layout of the pool area complied with Standards New Zealand Standard for Swimming Pool Design and met the relevant requirements for PoolSafe standards. However, there was a blind spot created by the separating wall between the toddlers’ pool and the learners’ pool. The lifeguards were all aware of this blind spot.”
The review also found lighting and water glare could be problematic at certain times of the day due to the reflection from the windows, this could have prevented Ranger from being seen when he was in the water.
It also noted that there was only one CCTV camera that provided a view of the learners’, toddlers’, adults’ and spa pools. That camera view was obstructed by a pillar.
An unobstructed camera would not have prevented the death, Woolley said.
Two-year-old Ranger Hetaraka was found floating face down in a pool at the Napier Aquatic Centre in late 2020. Photo / NZME
The review stressed that the contributing factors leading to the death included the fact Ranger was left unattended in the water, the lifeguard had to deal with issues in another pool at the time that the toddler entered the learners’ pool, and the glare created on the water’s surface.
The council took numerous steps following Ranger’s death. These included installing new signage and three new CCTV cameras as well as tinting the pool’s windows to reduce glare.
The pool has taken numerous other changes such as implementing “Pool Alone Policy” pamphlets and wristbands for younger children.
The pool also implemented a policy that if a family was warned about leaving a child unsupervised in the water, the child would be removed from the pool by the lifeguard and told they could not re-enter the pool.
