A swimmer drowned after a "flawed" lifeguarding system meant he was submerged for almost seven minutes before he was spotted, a court has heard.

Dominic Hopkins, 57, got into difficulties while swimming lengths at the University of East Anglia’s (UEA) Sportspark pool.

He was dragged from the pool, given CPR and taken to the Norfolk and Norwich Hospital by air ambulance, but he died the following day, on January 28, 2022.

Eastern Daily Press: Dominic HopkinsDominic Hopkins (Image: Newsquest)

Following the tragedy, the Health and Safety Executive (HSE) launched an investigation.

Garry Moon, an HSE inspector, told an inquest into Mr Hopkins death: “The question I was asked to look at while compiling my report was what factors were likely to cause the delay in getting to him.

“Mr Hopkins’ situation was not noticed for over six and a half minutes. It is a very long time.” 

At the time of the incident, Mr Hopkins - who was described as “a competent swimmer” - had been swimming breaststroke in the slow lane in the middle of the shallow end of the pool, with a depth of 1.2m.

Mr Hopkins, an accomplished violinist from Norwich, was a known epileptic.

He then suffered a fit, Norfolk Coroner’s Court was told. 

Eastern Daily Press: The swimming pool at the UEA's SportsparkThe swimming pool at the UEA's Sportspark (Image: Newsquest)

Mr Moon’s report explained how several factors caused a delay in help, and looked firstly at an industry-recognised system called 10:20. 

This system meant Sportspark lifeguards would scan the pool for five seconds and then the underwater camera screens - on their chairs - for five seconds.

If an incident occurred, they would then have 20 seconds to respond to it. 

The underwater camera screens used at the time were part of a system called Poolview and measured 94mm x 74mm (around 3.7ins x 2.9ins) each. 

While nine cameras had been in place, the HSE report focused only on eight of the cameras that allowed underwater vision.

Using the 10/20 procedure, lifeguards had 0.625 seconds – roughly double the time it takes a human to blink – to look at each screen before reverting to the pool scan.  

Although visible, Mr Hopkins was swimming in the least visible section of the pool and as a result would have appeared on the screen no bigger than 19mm.

A “blue hue” would have also impacted visibility, the report said. 

Eastern Daily Press: SportsparkSportspark (Image: Newsquest)

Mr Moon added: “He would have appeared less than one inch in length [on the screen]. 

“If he had been in a different lane, this would have been a different situation.

"And at the time, 10:20 was a well-used protocol but it was flawed.”

The inquest heard how, prior to July 2023, lifeguards across the leisure industry followed the 10:20 technique to supervise swimming pools, despite there being no research conducted to prove its effectiveness. 

Since then - and following extensive research by the Royal Life Saving Society UK - a system called the 'natural scan method' has been developed to replace 10:20. 

The Sportspark has since adopted the natural scan method, but it would not have been available at the time of Mr Hopkins’ death. 

The site has also upgraded to Poolview Iris, a system that uses artificial intelligence to detect when a swimmer is in difficulties in the water. 

Mr Moon went on to explain the difficulties of seeing Mr Hopkins underwater too. 

As well as being considered “low risk” by swimming in the slow lane in the shallow end, he appeared to be in a “natural position” and did not display any abrupt changes or noise.  

“Generally, people at the bottom of the shallow end is not uncommon,” he added. 

“Even a lifeguard paying attention still could have missed him. 

“He was difficult to see – detection was hard.” 

A witness who alerted the lifeguards to Mr Hopkins’ condition had also swum for four lengths before she noticed he was in trouble, evidence revealed. 

A final factor that may have impacted response time was glare. 

A previous risk assessment carried out at the pool showed “significant glare” in the area Mr Hopkins was swimming. 

Poolview was installed in 2014 to help to alleviate the issues arising from that concern. 

A statement from the UEA said: “UEA Sportspark is deeply saddened by the passing of Dominic Hopkins. We would like to take this opportunity to pass our sincerest condolences to his family and friends. 

“The safety of our pool users has, and always will be, our priority.  

“Following this incident, a full investigation took place. Where required, steps were taken to strengthen and update existing procedures and new technology was introduced.  

“UEA Sportspark has cooperated with and supports the coroner’s findings and conclusion.  

“The HSE investigated this incident and found that the UEA complied with good practice and adhered with the then current guidance.” 

Reaching a narrative conclusion, area coroner Yvonne Blake said: “Mr Hopkins died as a result of multiple organ failure, secondary to drowning precipitated by an epileptic fit while drowning.”