The pool's manager, its assistant manager and the regional director of the Department of Conservation and Recreation were asked to resign for their roles in keeping the state-run Fall River pool open on June 26 when 36-year-old Marie Joseph drowned accidentally. A fourth employee, the agency's district manager with oversight of the pool, was placed on leave.
"We think bad decisions were made," said Edward Lambert, commissioner of the Department of Conservation and Recreation. "The pool should not open if there is a water clarity issue."
State officials released the preliminary findings of an investigation into the drowning and what happened during the two days that Joseph's body lay at the bottom of 12 feet of milky water.
Investigators said a review of surveillance video showed Joseph going down a water slide into the pool's deep end, surfacing briefly and bumping into a child before going under. The entire sequence lasted only six seconds. The video showed no signs of Joseph struggling, investigators said.
Carl Rudge, chief park ranger for the state agency and the lead investigator, said one of four lifeguards on duty at the time of the accident was supervising the water slide. Rudge noted that department rules require that two lifeguards monitor the water slide and that diving blocks be closed while the slide is in use - something that also was not done.
Investigators stopped short of blaming the lifeguard near the slide, saying her attention may have been diverted by a group of other swimmers. After Joseph slipped beneath the water, lifeguards were unable to see her because of the cloudiness of the water, Rudge said.
A short time after Joseph went under, officials closed the deep end of the pool because of the cloudy water but allowed the rest of it to remain open, another violation of protocol, investigators said.
Joseph, a native of Haiti and mother of five, worked as a hotel housekeeper in Newport, R.I. Her body did not surface until the evening of June 28, more than two days after she drowned, when youths jumping a fence for an after-hours swim discovered it.
Massachusetts pools are expected to be crowded over the next several days as a heat wave that has gripped much of the nation's midsection moves eastward. Lambert said he was confident the state-run facilities are safe.
"This tragic event leaves heavy hearts in an agency that prides itself on its ability to provide high quality, safe, recreational opportunities," he said.
Investigators said they were unable to corroborate a report that the boy who Joseph bumped into told two lifeguards about the incident.
The boy's mother told the Boston Herald that her son told lifeguards that Joseph did not resurface. She also said a lifeguard told the boy that they would check, but never did.
The pool's entire staff was placed on administrative leave after the body was found and officials closed all 24 of the state's other deep-water swimming pools for inspection. All were later reopened except for the one in Fall River, which was drained.
Six similar water slides at other state-run pools have been closed while officials review procedures, Lambert said.
The Fall River pool is 12 feet deep and employs 12 staffers, six of whom are lifeguards and are certified by the Red Cross.
Two city inspectors checked the pool on the day after the drowning and again on the following day, but according to Mayor William Flanagan, the inspectors noted only that the waters seemed cloudy.
Flanagan also said the pool's permit had expired on Dec. 31.
Protocols require that the grates at the bottom of pools always be visible, but a review of the video showed the water began to cloud up on Saturday - for reasons that remain unclear - and remained murky for the next few days.
Bristol District Attorney Samuel Sutter is continuing a separate investigation into the circumstances of Joseph's death and is in possession of the surveillance video that was reviewed by the state. No criminal charges have been filed.
Gov. Deval Patrick ordered the state review, calling the case "terrible," and "bizarre."
Dr. Lauren Smith, a state public health official, said the presence of the body in the pool was unlikely to pose a health risk to other people who continued to swim.
