Research Summary: What does drowning look like?

Homepage > Research

Drowning is a rare, ill-defined target with non-exclusive features and is multi-dimensional (Lanagan-Leitzel, 2015). What is clear is that the successful detection of drowning pool users is underpinned by observer knowledge. Whilst some drowning behaviours are more widely recognized than others, as far as UK swimming pools are concerned, the less recognizable patterns result in the worst outcomes for pool users. That raises the question, what do drowning pool users look like? 

Instinctive drowning response (IDR) theory

A study by Pia (1974) utilized water incidents caught by recording devices to develop the instinctive drowning response (IDR) theory. This theory has long been responsible for the common media and public misconception that all drowning persons with eyes fixed on the shoreline, horizontal arm movements under the water surface, and audible screams whilst waving for help. 

International Drowning Researcher's Alliance (IDRA) study

Twenty members of the International Drowning Researcher's Alliance (IDRA), representing Australia, Brazil, the UK, Greece, New Zealand, Portugal, Spain and the USA, sat down in 2019 to review video-recorded footage of real-life water incidents. 43 videos, including a continuous recording of the incident, from instigating events to recovery, were analysed. 

Members independently watched one video at a time, noting, using a standard form, information about age, gender, location, time, activity, movements, use of floatation devices, presence of others, and body position.

• The water body type in 21 (87.5%) of the footage was swimming pools, with the remaining 3 (12.5%) in open water. 
• 18 (75%) incidents involved a baby or child, and the remaining 6 (25%) involved adults.  
• 8 (33%) of the incidents occurred with no other persons in the water, with the remaining 16 (66%) having persons in the water. 
• Only 1 incident was resolved by self-rescue. A rescue resolved the remaining 23.  
• A lifeguard was present in 8 (33%) cases, with the remaining 16 (66%) incidents taking place in locations without a lifeguard providing constant poolside supervision. 

The following trends of 52 persons in 42 videos where the instigating events were observable were particularly noteworthy: 

• In 16 (30%) incidents, the individual submerged immediately. 
• In 16 (30%) incidents, the individual struggles before submersion. 
• Ladder climbing behaviours were observed in only 3 (6%) incidents. 
• Distress was visible in only 6 (11%) incidents.  
• In 13 (25%), bystanders appeared to look at the person in danger without taking action. 
• Children appeared to be playing alone in 19 (36%) incidents. 
• In 9 (17%) incidents, children appeared to jump into the water confidently before discovering they could not safely return to the side. 

The following results for persons not rescued before unconsciousness were notable, albeit a small sample size of 5, which requires further research to support observations: 

• Spontaneous body movements above the water's surface lasted between 106-132 seconds once the drowning process began. This exceeded the average duration of visible drowning behaviours, which lasted between 76-96 seconds. 
• Casualties took 6-95 seconds before submerging them for the final time. Once submerged, casualties remained underwater for between 34-132 seconds. 

What does the subjective experience of drowning tell us about the signs of drowning?

In a study of the subjective experiences of drowning, Tipton and Montgomery (2021) analysed themes by reference to the six stages of drowning:

1. Struggle to keep the airway clear of the water. 
2. Initial submersion and breath-holding. 
3. Aspiration of water. 
4. Time to unconsciousness. 
5. Time to cardio-respiratory arrest. 
6. Death, inability to revive. 

Common themes within subjective accounts included a period of panic and pain, with descriptions of a tearing, burning sensation in the chest, often followed by a feeling of tranquillity and peace before falling unconscious. 

These descriptions suggest the following observable characteristics may be present when detecting drowning casualties: 

• Facial expressions or body movements which indicate panic and a desire to change body position, which, as time elapses, go unsatisfied, may be an observable sign of drowning. 
• Drowning casualties in the latter stages of drowning may relinquish their desire to change body position as an aura of tranquillity and peace sets in. A lack of movement should not be construed as a pragmatic decision to remain underwater but instead as a reaction to an inability to change one's body position. 

One limitation of subjective accounts of drowning is they tell us little about the signs of drowning beyond the point of unconsciousness in cases where the above stages are present. Subjective experiences of drowning also provide an incomplete picture of how people can drown, as casualties who lose consciousness suddenly and without warning may be unable to recount any subjective experience. The signs of drowning in such cases may be absent from the features identified above but share similarities with the signs of drowning in casualties who have lost consciousness.  

Key takeaways

Visualizing drowning persons is a low-frequency event, where observers often miss instigating events, and scant published data exists. More work is needed to collate a substantial media library to advance our understanding of drowning behaviours to improve lifeguard training and public awareness. 

Our best assessment of the signs lifeguards and others should look for to detect a drowning person or warrant investigation of a potential drowning person may include: 

• A panicked expression.
• Unable to respond verbally to confirm they are ok. 
• Sudden onset of erratic movement of the limbs which do not propel the body forwards.
• Inability to keep their head above water, despite effort applied to do so. 
• Inability to change body position, despite effort applied to do so. 
• An absence of propulsion to move the body forwards. 
• A set of behaviours that differ from the observed pattern of behaviour that preceded it. 
• Any person under the water for 30 seconds or more without prior permission.

Behaviours that should not mislead lifeguards and others to rule out that a person is drowning may include: 

• Turning my head to look in your direction. 
• Presence of small movements that do not propel the body forwards, particularly where these are present on only one side of the body. 
• Body position is anything other than face down in the water (such as upside down, sitting upright, leaning forward). 
• A movement that might appear to be a wave or thumbs-up action. 
• A material change in the pattern of behaviour observed in a swimmer undertaking hypoxic training or breath-holding behaviour. 

References

Carballo-Fazanes, A., Bierens, J., et al. 2020. The visible behaviour of drowning persons. A pilot observational study using analytic software and a nominal group technique. International Journal of Environmental Research and Public Health. 17, 6930. 

Lanagan-Leitzel, L., Skow, E., and Moore, C. 2015. Great expectations. Perceptual challenges of visual surveillance in lifeguarding. Applied Cognitive Psychology. 29, 425-435. 

Pia, F. 1974. Observations on the drowning of non-swimmers. Journal of Physical Education.  71, 164–166. 

Tipton, M. and Montgomery, H. 2021. The experience of drowning. Medico-Legal Journal. 0(0), 1-10. 

Citation: Jacklin, D. 2022. What does drowning look like? Water Incident Research Hub, 28 January.