A coroner says bathers of a Rotorua hot pool should be better supervised and not allowed to put their heads underwater after a French tourist was found dead in 2018.
Denis Miklus, 67, was found floating face-down in the 42C Priest Pool at Polynesian Spa four years ago on June 19, 2018. An inquest into his death was held in Rotorua in July 2019 and Coroner Matthew Bates last month issued his finding.
The Rotorua Daily Post has now obtained a copy of the finding.
Miklus was spotted face-down in the pool but staff at the time didn't think it was unusual and didn't want to immediately disturb him in case he was relaxing or doing exercises under water.
Coroner Bates has made several recommendations and comments in the 48-page finding relating to staffing and procedures at Polynesian Spa on the day of Miklus' death.
His recommendations include ensuring better supervision of bathers and stopping the practice of bathers putting their heads under water. He's also recommended refresher training for reception staff to ensure they tell customers about drinking water and reviewing staff members' qualifications.
The finding said Miklus, a retired mechanic and car salesman, was considered fit and healthy with no ongoing medical conditions.
He lived with long-time partner, Jany Toomaru, in Tahiti and the pair would visit New Zealand annually for holidays. They had previously owned a holiday home in Hamurana.
Toomaru dropped Miklus at the Polynesian Spa at 11.43am and agreed to pick him up about an hour later while she ran some errands.
It wasn't known if he went straight to the 42C pool or if he used a cooler one earlier as there were no CCTV cameras installed at that time, the finding said.
A duty manager started at 1pm and walked around the pools to make sure everything was okay. She noticed Miklus was floating face-down in the pool and tried to get his attention by calling out to him. He didn't respond.
Her initial thought was he was holding his breath, doing some kind of exercise and relaxing. She didn't want to interrupt him as she had seen other customers in the past behaving in a similar way and therefore didn't think it was unusual, the finding said.
She then went to speak with a lifeguard, who didn't have an immediate view of the private pools. The lifeguard was in the process of doing other duties at the time.
The duty manager told the lifeguard about the man floating and the lifeguard commented he might be exercising.
The duty manager went back to the Priest Pool and waited about 40 to 50 seconds for Miklus to surface. When she realised something was wrong, she went back to the lifeguard to get help.
The lifeguard turned Miklus over and his lips were blue, his body was pale and his tongue appeared lodged in his throat. He wasn't breathing and had no pulse. CPR was started.
As emergency services arrived at the Polynesian Spa, Toomaru was in the cafe waiting for her husband, unaware the commotion related to her partner, the finding said.
Emergency services couldn't revive him.
Coroner Bates ruled out the possibility of hydrogen sulphide poisoning early on in the case, saying he didn't intend to reinvestigate the issue as either a direct cause of death or a cause of loss of unconsciousness.
"I was satisfied, having considered the evidence already available, that neither of those scenarios was likely. I did not therefore require the attendance of an ESR scientist, the pathologist or another expert to provide evidence on those matters," Coroner Bates' finding said.
Hydrogen sulphide gas is released when bubbles containing it reach the surface of the water. It is a poison that can paralyse your breathing system and kill in minutes. Even in small amounts, it is considered dangerous to your health, the finding said.
There were certain levels that hydrogen sulphide must not exceed to remain safe. The finding said WorkSafe had confirmed Polynesian Spa's safety systems around hydrogen sulphide had been examined and there were no concerns.
There was also no hydrogen sulphide detected in Miklus' blood or urine, the finding said.
Coroner Bates instead agreed with pathologist Dr Tim Sutton it was likely Miklus had fainted as he stood up to leave the pool and had landed face-down in the water, then drowned.
The finding said the coroner's process was paused while WorkSafe investigated. WorkSafe later found there was insufficient evidence to show Polynesian Spa had breached its primary duty of care to Miklus. It found there was nothing Polynesian Spa could have done to prevent his death and it was recommended no further action be taken.
Coroner Bates' recommendations said there was no evidence Miklus was observed between 12.30pm and 1pm and it was the duty of Polynesian Spa to provide constant supervision in the adult pools area.
The complex also had a responsibility to remind bathers about regular breaks and hydration, the finding said.
Coroner Bates said the complex was short-staffed on the day and he concluded from the evidence it was one lifeguard down.
He said in the future Polynesian Spa should consider closing or delaying the opening of certain areas until replacement staff were on site and it should never be a "business as usual" approach with reduced staff.
Polynesian Spa responded in the finding that it maintained there was no short staffing and the family pool area would have been closed until suitable cover was in place, which was standard practice.
Polynesian Spa chief executive Gert Taljaard said in evidence bathers often wished to enjoy the pools while being left alone and not policed or interrupted and it could be a balancing act for staff.
However, Coroner Bates said it shouldn't be.
"The risk of annoying or interrupting a bather who may be relaxing or performing some type of exercise in higher temperature thermal pools is far outweighed by the need to ensure their safety at all times."
He said there should be a policy that all bathers be advised at the point of contact with staff and through signage not to submerge their head or face in the higher temperature pools due to the increased risk of heat exhaustion, dehydration and fainting.
He also said it should be policy that staff intervene immediately if bathers were seen under water in those pools.
Coroner Bates also recommended a permanent placement of a lifeguard with unobstructed views of the Priest Pools. If a staff member can't permanently be put at the pools, Polynesian Spa should install CCTV cameras to monitor them, the coroner said.
Polynesian Spa responded to the coroner's recommendations in the finding, saying controlling the time bathers spent in pools wasn't possible.
However, it said it conveyed safety messages about breaks and drinking water both personally and via signage. It said the Priest Pools were checked regularly as part of roving patrols of the adult pools.