The public swimming pool where the body of a woman lay unnoticed for more than two days should never have been opened on the day she drowned because the water was too murky, state investigators said Wednesday.
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.
A city health inspector also has been fired.
"We think bad decisions were made," said Edward Lambert, commissioner of the state 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.
"Water clarity was the primary factor in preventing lifeguards from being alerted to the drowning and from subsequently detecting Ms. Joseph at the bottom of the pool after she submerged," said Carl Rudge, chief park ranger for the agency and lead investigator.
Rudge said one of four lifeguards on duty at the time of the accident was supervising the water slide, but he noted that department rules require that two lifeguards monitor the 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.
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.
Five similar water slides at other state-run pools have been closed while officials review procedures, Lambert said.
Fall River Mayor William Flanagan told The Associated Press that on Wednesday he fired a city health inspector who checked on the pool two days after the drowning, while Joseph's body was still at the bottom and other people continued to swim in it. Flanagan said the inspector should have taken action to protect other swimmers after noting that the water was cloudy.
A second inspector who had been placed on administrative leave was reinstated after it was determined that she had not seen the water, Flanagan said.
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 continued to be murky for the next few days, the state investigation found.
In the future, water clarity at all pools will be tested using a 5-inch black and white disk that must be visible at the bottom of a pool before it can open, Lambert said.
Gregg Miliote, a spokesman for Bristol District Attorney Sam Sutter, said Wednesday that the DA is continuing a separate, "intensive investigation" into the circumstances of Joseph's death, that he hopes to conclude next month. 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.