People were "running around like headless chickens" after a youngster was pulled lifeless from the swimming pool of a holiday hotel in Egypt, an inquest heard.
Four-year-old Kyle Hirst had wandered away from his stepfather and fallen into the water.
He was rescued from the bottom of the pool by one of the guests and another holidaymaker, Elizabeth Illingworth, tried to revive him using mouth-to-mouth resuscitation.
Mrs Illingworth, who is a British Transport Police officer, described the situation as "just mayhem" and added: "There were no facilities on the poolside for first aid. They were running around like headless chickens.
"Even in basic Spanish hotels they have a guard just monitoring the pools."
She said the fact that it took an ambulance about 25 minutes to arrive at the hotel was "disgraceful."
The Bradford hearing was told that, after arriving at hospital, Kyle was placed in intensive care.
His foster parents, Stephen and Karen McKenzie, of Long Lee Lane, Keighley, took it in turns to visit him while the other looked after his younger brother.
But, on what was to be the final visit, Mrs Mckenzie noticed that the ventilator was not working and was told by a doctor: "Oh, he's dead."
She said that at no time were they consulted about Kyle's treatment or the decision to switch off the machine.
Recording an accident verdict, deputy coroner Mark Hinchliffe said that although the Nubian Village Hotel in Sharm-el-Sheikh presented itself as suitable for families, there was a strong impression there was no direction, no authority and no protocol to be followed in such incidents.
There was nobody in authority to take charge or to be able to take charge, resulting in mayhem.
There was a large sign stating that all activities around the pool were at the guests' own risk and there was no lifeguard.
Referring to the hospital treatment provided, Mr Hinchliffe said: "It does seem that Mr and Mrs McKenzie feel that their feelings and important role was marginalised. They were not informed or considered as one might expect here in the UK.
"I sympathise greatly with their feelings on that score. This could and should have been better managed, but I cannot say that the outcome would have been any different.
"It is more than possible that, with the best treatment in the world and the most immediate resources at the resort, still Kyle could not have been saved."
The little boy died from broncho-pneumonia due to a lack of oxygen to the brain, caused when he inhaled a large amount of water. He had accidentally fallen into the adult pool after wandering away from his stepfather.
No-one saw him go and it was impossible to say whether he had suffered a fit or tripped. He might have panicked after falling into the pool because of his obsessive dislike of water on his face.
An Italian man saw him in the pool and shouted out to one of the guests, Peter Flack, who went into the water and brought him out.
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