A coroner demanded an overhaul of resuscitation training after hearing how a teenage swimmer was revived at a poolside, only to die when a lifeguard stopped giving her mouth-to-mouth too soon.
Sophie Konderak had a cardiac arrest moments after starting a training session at a leisure centre.
The 16-year-old was dragged from the water unconscious and young lifeguard Katy Butler began cardiopulmonary resuscitation – mouth-to-mouth breathing and chest compressions.
Swimming star: A lifeguard left Sophie Konderak to die after wrongly believing she had saved her life
Miss Butler, 23, who had never tried to revive a swimmer before, believed she had saved Sophie when she started breathing again.
However, she did not take the crucial step of checking for a pulse – to determine whether the heart had restarted – and unwittingly left Sophie dying on the wet floor.
Paramedics arrived four minutes later and resumed CPR, only to be asked by one of the lifeguards: ‘Why are you doing CPR? She’s alive,’ the hearing was told.
As a paramedic gave evidence to the inquest, the teenager’s distraught mother, Lesley, 46, broke down in tears and cried out: ‘It’s my child’s life, why didn’t anybody do anything?
Braunstone Leisure Centre’s lifeguards had received ‘insufficient training’
‘How could you just leave her lying there? She would have survived.’
The ambulance crew tried to revive Sophie, a talented swimmer who dreamed of winning Olympic gold, with a defibrillator at the leisure centre in Braunstone, Leicester, on September 15 last year.
However, she was pronounced dead shortly afterwards at the city’s Royal Infirmary.
The inquest heard Sophie’s initial cardiac arrest was caused by an undiagnosed heart condition.
Heart expert Dr Christopher Duke said Sophie would have survived if she had received continuous CPR. He said: ‘You don’t stop resuscitation just because a patient appears to be breathing. You only stop if there’s breathing and a pulse.’
The inquest on Wednesday heard that Miss Butler, who was employed by Leicester City Council and was performing CPR for the first time, spent four minutes trying to revive Sophie and believed she had succeeded when the teenager began breathing.
She said: ‘If a person is breathing we’re told to stop CPR and put them in the recovery position.’
Sophie’s heart was not restarted by the defibrillator until 4.52 pm – 14 minutes after she was pulled out of the pool.
The inquest heard the lifeguards had been trained by the Royal Life Saving Society, a charity that provides training and education in lifesaving.
Recording a narrative verdict, coroner Catherine Mason said she would write to the Resuscitation Council of the UK, which provides guidelines for life-saving techniques, to ask it to amend its training guidelines to include checking for a pulse.
Mrs Mason, the coroner for Leicester and South Leicestershire, said: ‘The crucial point of this is that the CPR was stopped.
‘The guidelines should be changed so that from when CPR commences it is conducted until a medically qualified person arrives or the patient regains consciousness.’
After the inquest, Mrs Konderak and Sophie’s father, John, said the ‘shortfall in the level of training and equipment contributed to their daughter’s death.
They added: ‘We hope the coroner’s recommendations will lead to an improvement in lifesaving training and no further lives will be lost.’