Premature Termination of CPR Cited in Death (UK)

02.03.2010

Girl swimmer, 16, died after 'wrongly trained' lifeguard stopped CPR thinking she had saved her life

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.

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 an 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 defibrillator until 4.52pm - 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 which 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, 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.'


Here's what readers of this article online have had to say:

Heart wrenching story. The lifeguard was probably a teen as well (they all are in America). Can you imagine having to live with your mistake for the rest of your life?

In Florida, all high school students are required to be CPR certified in order to graduate. I don't know about the other states requiring CPR, as the US school system is ruled by federal guidelines for reading, math, etc. but allows individual states to decide graduation requirements.

- Lisa, Jacksonville, Forida, USA, 25/2/2010 14:35

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Such an unnecessary tragedy.
Sadly though I bet the life guards have got a battery of pretty certificates issued by the council or some "muppet" authority proclaiming their competence in CPR.
Also I would suggest that while we live in a world of idiotic "elf and safety" nobody will be fired for this shocking incompetence.
R.I.P. Young lady

- Gordon Gregory, Expat in South America, 25/2/2010 14:26

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Very Sad, I have myself given CPR 4 times, none of them lived,but i tired my best and i was probably performing CPR on a corpse on most if not all off them,but i had to been seen to be doing something.[ car crashes ]
My point is no amount of training can prepare you for the real thing, but in this case there should have been more than one qualified person, so the failing should be aimed at the organisation [ pool owner ] rather than the poor person that thought that they were doing their best.

- andrew, Kent, England., 25/2/2010 14:22

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i am trauma first aid trained and was told that once breathing has resumed cpr is to stop because to continue it would have damaging effects. I was informed not to look for a pulse because it can be very difficult to find and time is lost in the vital first few seconds of treatment

- ian mason, great yarmouth, 25/2/2010 14:16

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I went on my first aid at work refresher course last yr and they dont even teach you how to check for a pulse. I dont think the lifeguard is responsible, Its scary but I probably would done exactly the same thing! I think the whole first aid training needs to be reviewed!

- Sarah, Swansea, 25/2/2010 13:58

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I am a first aider, and we are also taught they if they are breathing, then the the heart must be beating. Once they are breathing unaided, stop cpr and put into recovery position. It wasn't the lifeguards fault. Poor girl must feel awful.

- Danielle, suffolk, 25/2/2010 13:58

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