Overview
- Housekeeping manager Joanna Lloyd said she carried out daily checks, but the coroner questioned blank log entries and daughters testified they saw no staff at the tub.
- Log sheets showed early-morning checks on the Saturday and Sunday, yet family members disputed those visits, saying their dogs would have alerted them to anyone approaching.
- Venue manager Chloe Baker acknowledged she did not scrutinize maintenance logs or routinely observe full clean-and-refill procedures, and the logs were unavailable to Environmental Health during a February 19 visit.
- An internal review on February 21 recommended twice‑daily testing, smart meters to flag water issues, stronger flushing in peak season, on‑site safety guidance, and additional staff training.
- The coroner highlighted that a 2015 Legionella risk assessment was not updated after hot tubs were installed in 2016 and that daily maintainer Lloyd had not taken a Legionella course, unlike managers.