It’s been two months since a drowning death that went unnoticed for more than two days in Fall River, Mass., garnered national headlines.

While officials continue to deal with the aftermath, one health inspector, two aquatics staff members and a supervisor have resigned. Aquatics experts say the incident points to the need for better education.

“Any way you look at it, there was a lack of training, competency and responsibility. This incident was not only tragic for [the victim] and her family, but for the aquatics industry,” said Jesse Benavidez, an aquatics professional from Conroe, Texas, in a post on AI Connect Aquatics International’s social network.

Marie Joseph, was last seen at the Veterans Memorial Pool alive on Sunday, June 26. On Monday and Tuesday, the pool was open to the public with six lifeguards on duty (four at a time). When her body was discovered Tuesday night, the Bristol District Attorney’s Office and Massachusetts Department of Conservation and Recreation, which operates the pool, began investigations.

“This tragic event leaves heavy hearts in an agency that prides itself on its ability to provide high-quality, safe, recreational opportunities for the residents of the Commonwealth,” said DCR Commissioner Edward M. Lambert Jr. in a press release. “We hope that, as an agency, we will continue to work to restore and maintain the public’s confidence in our ability to fulfill the mission expected of us....”

Surveillance video indicates dangerously cloudy water caused Joseph’s body to go unnoticed. Inspectors visited the pool and reported poor water clarity, but the facility was not closed, which is considered standard practice.

The incident is similar to the 2002 drowning of 7-year-old Paolo Ayala, noted Alison Osinski, Ph.D., owner of Aquatic Consulting Services. He drowned at a birthday party at a Los Angeles home. Like Josephs, he was not immediately discovered because of cloudy water.

“One of the seven deadly sins is having cloudy water,” said Tom Griffiths, founder of Aquatic Safety Research Group in State College, Pa. “It’s just a lack of vigilance on the part of the pool manager.”

Following hearings, the health inspector who approved the pool was asked to resign, along with two pool managers and their supervisor, the DCR Southeast regional director. As of press time, the rest of the Veterans Memorial pool staff was still on administrative leave; the pool had been closed and drained.

Joseph was last seen alive on the pool’s water slide. The preliminary investigation revealed that only one lifeguard was on duty at the slide, another violation. Per DCR policy, Griffiths said, “there should have been two guards watching that slide.” 

The DCR owns and operates more than 20 pools, and all were closed briefly for inspection following the incident. Lambert ordered that slides at six pools remain closed until a thorough review is completed. Additionally, in response to the incident, the DCR has implemented several policy changes. Water quality testing at all facilities now will be done with a Secchi disk.

To determine water clarity, the black-and-white, 5-inch diameter disk must be visible when placed on the pool floor. Also, required pool checks now must include in-water inspections in addition to on-deck visual looks.

The Bristol County DA’s Office cannot speculate on next steps, said Gregg Miliote, director of communications. Further DCR policy changes will depend on the investigation’s final outcome, added DCR spokesperson S.J. Port.

But industry experts say one thing is clear: Better operator training is needed. “Just because you took a CPO class, how much do you really know?” Osinski said. She emphasizes the importance of ongoing education.

Consumers also need to be vigilant, said Linda Golodner, president emeritus, National Consumers League and a founding member of the Water Quality & Health Council.

“This emphasizes that everyone is responsible for assuring that a pool is safe,” said Golodner, a noted water safety advocate who was named to Aquatics International’s Power 25 list. “You cannot just depend on the lifeguards, the pool operators or others to be sure your pool is clean and safe. It is everyone’s job.”