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4 lose jobs in pool death

Victim unseen in cloudy water

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By Ben Wolford
Globe Correspondent / July 21, 2011

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Four people have lost their jobs after investigations into a drowning in a state-run pool concluded that their inaction led to the death of a Fall River woman whose body lay concealed by cloudy water in the deep end for two days, officials said yesterday.

Two pool managers and their supervisor in the state Department of Conservation and Recreation resigned after an inquiry found they violated safety guidelines by leaving the murky pool open, DCR officials said. And a Fall River health inspector was fired for approving the pool for use, even while the body of Marie Joseph was still at the bottom, Mayor William Flanagan said.

The departures were announced as investigators described the last moments of Joseph’s life, captured by a surveillance camera at the pool.

Reviewed as part of DCR’s investigation, the footage shows Joseph, 36, slipping down a slide behind a child and plunging into the water, investigators said. Three seconds later, they said, Joseph surfaced and appeared to make physical contact with the child. She briefly submerged again, as the child swam to the edge of the pool near the slide, before rising one last time and finally disappearing from view.

Four lifeguards were on duty the afternoon of June 26, investigators said, and one was stationed at the deep end near the slide. But none of them reacted, said Chief Park Ranger Curt Rudge, who is leading DCR’s investigation.

“At no time does the video indicate struggle at the surface of the water,’’ Rudge said.

The child who slid down ahead of Joseph was a 9-year-old Fall River boy. The boy’s family told reporters shortly after the drowning that he had tried to pull Joseph to the surface and, when he could not, attempted to notify lifeguards. Rudge said yesterday that investigators could not substantiate those reports.

“While the video and staff interviews do not provide corroboration of these reports at this time, we continue to include this question as part of our investigation,’’ he said.

The initial results of DCR’s internal review, released at a press conference yesterday, were the first public glimpse of the sequence of events surrounding Joseph’s death, compiled from the video footage and more than two weeks of interviews with 21 DCR employees, including the lifeguards, officials said.

The entire staff of the Fall River pool remains on administrative leave, said DCR Commissioner Edward M. Lambert Jr.

“The investigative team believes that water clarity was the primary factor in preventing lifeguards from being alerted to the drowning and from subsequently detecting Ms. Joseph at the bottom of the pool after she submerged,’’ Rudge said.

Lambert said the three state employees resigned at his request, based on their part in the decision to open the pool June 26 and for leaving the water slide staffed by only one lifeguard, even though safety policies require at least two.

Last week, Flanagan launched a disciplinary hearing to determine whether two health inspectors who visited the pool violated city policies. One of them, 10-year city inspector Roger Casavant, carried out an inspection June 28, two days after the drowning, and noted the water was cloudy in his report.

Casavant, who was fired yesterday, did not notify authorities or recommend closing the pool, Flanagan said. He instead issued a city permit, which was never delivered because Joseph’s body was discovered later that night.

“He took no action,’’ Flanagan said. “If he had taken some action, he would have been fulfilling his responsibilities to the public that he served.’’

Separately, the Bristol district attorney’s office has been investigating the incident for three weeks, but has not released any findings.

The inquiry is expected to be completed in August, said Gregg Miliote, the office’s director of communications.

In addition to the three DCR employees who resigned, the district manager who oversees the Fall River pool was placed on administrative leave and could also be subject to sanctions, said Lambert.

He did not release the employees’ names.

When the pool opened for the season June 25, the water was “somewhat cloudy,’’ Rudge said, but grates at the bottom of the 12-foot deep end were visible. Over the day, the water became murkier, and by June 26, the grates could not be seen from the surface, the investigation found.

Rudge said DCR has hired an independent contractor to examine what caused the cloudiness.

Twelve minutes after Joseph disappeared under the water, workers closed the deep end of the pool, citing the water clarity, the investigation found.

On June 27, a pool contractor recommended leaving the deep end closed while allowing the filtration system to work.

The deep end remained closed until Joseph’s body was discovered June 28, while the rest of the pool was open to the public.

In addition to the personnel changes, Lambert ordered six water slides at other DCR pools closed until the department can review its practices.

DCR will also implement two new standards for its pool inspections: mandating that pool managers be able to see a 5-inch black and white disk at the bottom of pools before opening them and requiring lifeguards to go in the water during routine pool checks, Lambert said.

Travis Andersen of the Globe staff contributed to this report. Ben Wolford can be reached at bwolford@globe.com.