Maddox James Yellow Wings of Brocket, Alta., had been swimming with several relatives at the Ramada Hotel's water park in Lethbridge on Sept. 6, 2010.
When his parents were getting ready to leave, they realized he was missing.
"After what appears to be a brief number of minutes looking for Maddox by themselves, one of the family members notified the attendant lifeguards that the child was missing," says a fatality inquiry report examining the death.
A short time later, the boy's body was found at the bottom of the pool.
"Maddox was observed to be limp and not breathing. He was not wearing a life jacket or other floatation device."
The report released Tuesday says there was one lifeguard on duty at the time and about 30 to 40 people in the water.
The hotel later adopted recommendations from a safety audit and now has a minimum of two guards on duty at all times. It also removed a waterfall feature that obscured visibility of part of the bottom of the pool.
Provincial court Judge Gregory Maxwell recommended that all pools and spray parks in the province be required to have an independent safety audit before they open, as well as regular reviews.
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