Record of Investigation into Death (Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Stephen Raymond Carey, Coroner, having investigated a death of Elyssa Suzanne ROSEN

Find That:

a) The identity of the deceased is Elyssa Suzanne Rosen ('Ms Rosen');

b) Ms Rosen died on 26 October 2013 at Pearsons Point, D'entrecastreaux Channel, Tinderbox; 

c) Ms Rosen was born in Illinois, U.S.A. on 25 July 1965 and was aged 48 years and normally resided at 1440 McKinley Drive, Reno, Nevada, USA;

d) Ms Rosen was engaged to be married and an environmental consultant;

e) I find that Ms Rosen died as a result of drowning;

f) At the time of her death Ms Rosen was not being treated by a medical practitioner, and

g) No other person contributed to the death of Ms Rosen.

Circumstances Surrounding the Death:

 
Ms Rosen, who was an officer of the Pew Charitable Trust Environment Group, was in Tasmania as a member of a delegation from the USA attending a conference in Hobart organised by the Commission for the Conservation of Antarctic Marine Living Resources. She was the holder of a PADI open water diving certificate issued on 14 August 1992 but save for one cold water dive conducted in British Columbia in 2005, all of her diving experience had been in warm water.

The other members of the delegation attending the conference with Ms Rosen were John Hocevar, Claire Christian and Andrea Kavanagh. Ms Christian made enquiries of Susan Wragge, the owner/operator of Underwater Adventures Tasmania before coming to Tasmania, concerning the possibility of undertaking a diving charter whilst the group were in Tasmania. Discussions continued within the group and with Ms Wragge after their arrival which resulted in a drive trip being booked for 26 October 2013. The group met Ms Wragge and went on board the boat "Kahala" at approximately 10:00am on 26 October 2013. A safety briefing concerning the boat was given by Ms Wragge and discussions held as to the best possible dive site. Options were given taking into account the nature of the weather. Two options were identified; the Bruny Island kelp forest in Variety or Trumpeter Bays or the Tinderbox Marine Reserve. During discussions Ms Wragge was informed that Ms Rosen and Ms Christian had both done about 20 dives with little cold water dive experience whilst Mr Hocevar had done in excess of 500 dives including cold water diving. Based on this information Ms Wragge decided that the Tinder Box Marine Reserve dive was the most suitable as it had a flat bottom that increased in depth gradually and this minimised the need for the divers to adjust buoyancy, it allowed the divers to choose their depth between 5-12 metres, it was in a sheltered cove and there was plenty of variety offered for the divers to observe. The group were informed that the water temperature at the dive area would be approximately 12 degrees Celsius but that the provided diving gear was suitable for that purpose. Ms Rosen did, at this time, express some concern as to how cold it might be and she considered not diving if she found the water too cold. The group were also briefed by Ms Wragge as to the nature of the dive (although Ms Kavanagh was not diving), that they would be diving unguided and unsupervised as certified divers. All participants, including Ms Rosen, completed the Scuba Diving International General Liability Release and Express Assumption of Risk form relating to unguided and unsupervised boat dives for certified divers.

After approximately 45 minutes they arrived at the dive site and Ms Wragge described the area to them whilst also using a depth sounder to highlight underwater aspects. The boat was anchored, the area was sheltered from the westerly (off-shore) winds that were blowing; there was a slight surge but no waves. The diving equipment was then handed out. The wetsuits were 7mm thick with build in hood and Ms Rosen was provided with a two piece size 12 to try on. She commented that it felt restrictive and she was uncomfortable. It was explained to her that the suit needed to be a snug fit to avoid body temperature loss by water flushing. A size 14 was available and offered to her but after discussions with others she decided to keep the size 12 suit on. All divers were also using boots and gloves, the use of boots obliged Ms Rosen to use supplied fins as a personal pair she had bought with her would not fit over the boots. Ms Rosen used her own mask which had a snorkel attached.

Each member of the group was briefed by Ms Wragge concerning their equipment; in particular the weight system and buoyancy control device (BCD). Mr Hocevar recalls that:

"Sue gave each of us an individual briefing on the use of the dive equipment. With specific regard to the weights being used I recall clearly that Sue spoke to each of us individually and briefed us on the use of the weights, most importantly how to release them. I remember this clearly because there are many different types of systems, and this one I wasn't familiar with, so naturally enough I wanted to make sure I knew how to release them. All three of us had pocket weights, that is, weights which went into the pockets of our BCs."

Ms Christian states:

"Sue showed us how to operate the BCs and how to use the weights and how to release them. I felt comfortable with the level of briefing and information. I think she bought out certain weights for certain people, and I recall her asking about how much weight we each normally use, and our own natural buoyancy and so forth. She also spoke to us about safe ascent and so forth."

Apparently Ms Rosen and Ms Christian advised that they were not familiar with a weight integrated BCD and were provided advice about the inflate and deflate mechanisms and locations of alternate dump valves.

When all the equipment had been fitted and checked the divers entered the water. The extent of buoyancy was checked by operating the BCDs and Ms Wragge determined that Ms Rosen was sitting too high in the water and this was addressed by having Mr Hocevar attach two small ankle weights to her. Ms Wragge checked Ms Rosen's buoyancy again declaring it to be fine. After entering the water Ms Rosen was noted to be nervous about the dive, she had previously told the others that she experienced difficulties equalising and would for this reason need to descend slowly. Before entering the water Ms Rosen again clarified her BCD operation by inflating and deflating it and confirming with Ms Wragge the usage of the BCD during descent and ascent. After having her buoyancy adjusted, Ms Rosen expressed that she did not feel comfortable and that it was hard for her to breathe. Ms Wragge instructed her to swim to the rear of the boat, inflate her BCD and lay on her back. At this stage she appeared to be hyperventilating. Ms Rosen was reassured by the others; Ms Wragge explained the possible effects of the cold water, the need to get used to the weight of the equipment and the fact that breathing fast would be causing her to be uncomfortable. An offer was made for her to exit the water and try the larger wetsuit if she thought that this was the cause of her discomfort. However, after a further period and ongoing discussion, Ms Rosen appeared to calm down, her breathing pattern returned to normal and she relaxed. She then moved away from the boat and commenced her descent with the others. They regrouped midway and then moved as a group to the sea bottom. At that time Mr Hocevar says:

"From what I could tell everyone seemed to be fine, no one seemed to be having trouble equalising and everyone's buoyancy appeared fine. We stayed on the bottom at that point for a short time. Everyone indicated that they were fine and so we moved off. Everyone seemed quite comfortable, no one appeared to be having any trouble with their buoyancy or breathing. I took particular note of all of this, especially initially, because of Elyssa's nervousness on the surface."

They then moved off staying close together and within easy sight and touching distance of each other as advised by Ms Wragge. The group moved along together and at one stage observed a sea horse. Mr Hocevar says that Ms Rosen's attention was drawn to this, and she came up to look at the sea horse and that at this time she "…looked at the sea horse, and appeared excited. I was reassured by her excitement and the control she was showing over her dive."

Mr Hocevar and Ms Christian described how they regularly checked upon each other during the dive with Mr Hocevar commenting that he was taking particular note of how Ms Rosen was coping due to the nervousness she had displayed before the dive. After they had been diving about 20-25 minutes, Mr Hocevar noted that Ms Rosen was not with them. He estimated that it had only been approximately 10 seconds previously that he had seen her and she was fine. Mr Hocevar and Ms Christian waited a couple of minutes to see if she would reappear, when she did not they surfaced.

At this time Ms Wragge had been engaged as lookout for the divers and was observing their bubble trail. She then saw Ms Rosen surface, identifying her as she was the only one in the group with a snorkel. Ms Rosen was noted as positively buoyant and Ms Wragge formed the impression from her gesturing that she wished to be picked up. Ms Wragge moved to the bow of the boat and commenced retrieving the anchor at which time she noted Ms Rosen was facing away from her and had her face in the water moving from side to side as if she was looking for the other divers. Ms Wragge then heard Ms Rosen say something to her but she could not make it out, although she did not believe it sounded as if she was in distress. Ms Wragge then noted Ms Rosen slipped below the surface and saw a large amount of bubbles coming up around her consistent with Ms Rosen having dumped air from her BCD. Ms Wragge then moved the boat over to where Ms Rosen had been last seen.

Mr Hocevar and Ms Christian then surfaced near the boat. There was a verbal exchange between those in the water and those on the boat about losing sight of Ms Rosen during the dive and observations of her having surfaced. Mr Hocevar and Ms Christian were brought on board the boat which was then used to search the area before the anchor was again dropped near the original spot. After seeking assistance from the Marine Police and Ambulance by radio, Ms Wragge donned diving gear and, together with Mr Hocevar, entered the water and commenced a search for Ms Rosen. After about 5 minutes they found her lying on her back on the bottom, her regulator was out of her mouth and it was noted that her eyes were darkened and bulging. She was noted to have all her diving equipment still on. It was also noted that there was no air in her BCD; the pressure gauge showed there was still 95 bar of air in her scuba tank. Her BCD was then partially inflated and Ms Wragge and Mr Hocevar took her to the surface. Once they reached the surface they towed Ms Rosen towards the boat whilst Ms Wragge commenced mouth-to-nose rescue breathing upon Ms Rosen. 

Ms Christian and Ms Kavanagh assisted pulling Ms Rosen aboard and CPR was commenced. Further calls were made for assistance whilst these endeavours continued. The group were unable to administer oxygen from an oxygen unit on board as Ms Wragge had accidentally left the bag valve mask for the unit in her car.

Shortly after a Marine Police boat came along side and Ms Rosen was transferred to that vessel. This vessel made its way to the Kingston Beach boat ramp whilst one police officer assisted Ms Wragge to continue CPR. After arrival at the boat ramp an ambulance arrived and paramedics took over resuscitation efforts. Ms Rosen was conveyed to the Royal Hobart Hospital but was pronounced dead upon arrival.

An extensive investigation has been conducted by police with particular emphasis on ascertaining what caused or contributed to this tragic outcome. The circumstances leading up to the time of death were largely unremarkable. All persons participating were suitably qualified divers and the dive charter operator, Ms Wragge, and her vessel were appropriately accredited. Overall the activity was conducted in accordance with the Australian/New Zealand Standard 2299.3:203 Occupational Diving Operations Part 3, Recreational Industry Diving and Snorkel Operations. Before commencing the dive Ms Wragge briefed them on the conduct of the dive, ran through hand signals and recommended that they dive three abreast to maintain visibility of each other. She also highlighted hazardous marine life and a suggested route to follow. The diving equipment used by Ms Rosen, including her own mask and snorkel, was tested by staff at the Hyperbaric Unit, Royal Hobart Hospital and qualified police divers and no deficiencies which could reasonably be believed to have contributed to or caused her death were identified. The dive tank gas was shown to have higher than recommended water vapour content and the BCD had some leaks in an area but the reliefs and purges were all operational. The BCD was tested by a marine police diver and once inflated was able to maintain the diver on the surface for approximately 7 minutes before the test was concluded and before there was any need to reinflate. It was concluded that despite the BCD having a leak it was unlikely to have reduced the ability of the diver to remain afloat. There is no indication that the water content level in the air tank was a contributory factor. Indications are that Ms Rosen was in good health at the time and physically capable of undertaking the dive. There is evidence, however, that she did display a level of concern due to the dive being in cold water with the accompanying need to wear a thicker, and therefore more restrictive, wetsuit than what she was used to. She remained anxious about these aspects whilst preparing for the dive and when she had initially entered the water. The evidence of others present, however, established she was given opportunity to try a larger wetsuit or to withdraw from the dive and that she declined both options.

The evidence does not suggest that Ms Rosen was placed under any pressure or undue influence by Ms Wragge or the other participants to continue in the dive or to retain the equipment she had initially been provided with. To the contrary, the evidence indicates that considerable time was spent by Ms Wragge prior to the descent to reassure Ms Rosen and to ensure she was comfortable and ready to commence the dive. 

There is some discrepancy in the evidence concerning the fitting and use of the ankle weights. Ms Wragge recalls that she explained to Ms Rosen how to clip and unclip them whereas Mr Hocevar recalls:

"She handed two ankle weights to me, and I clipped them onto Elyssa's ankles. There was nothing said by Sue about the use or release of these, although they clipped together with a simple plastic clip and the operation was unremarkable."

These weights were used to adjust Ms Rosen's buoyancy as a quick and easy measure rather than removing the BCD and replacing it with heavier weights. Given their relatively light weight and the overall circumstances there was no reason to believe that they had any bearing on this accident other than reducing her buoyancy. The overall buoyancy however was controlled by the BCD.

The evidence of Mr Hocevar and Ms Christian is consistent and mutually corroborative indicating a high level of care shown between each of the three divers, particularly as to Ms Rosen due to her pre-dive concerns and anxiety. The dive was also proceeding well with no reason for concern until Ms Rosen was noted to be missing after only about 10 seconds from when last observed. Mr Hocevar and Ms Christian then ascended, Mr Hocevar in a more controlled manner than Ms Christian. Mr Hocevar was dumping air from his BCD as he rose to compensate for the reduction in pressure and the associated expanding of the air in the BCD whilst Ms Christian was not. On the surface, Ms Wragge noted two bubble patches, one large one and one small one. At the time, she thought that the large patch was indicative of and belonged to two divers whereas the small patch related to a third diver. Her belief, therefore, immediately before Mr Hocevar and Ms Christian surfaced, was that she was still observing three divers but it would appear she was mistaken as the large patch of bubbles is most likely to have been attributable to the purging of Mr Hocevar's BCD.

This mistaken belief as the sighting of three divers may have contributed to delay in initiating an underwater search. In addition, delay was occasioned by both Mr Hocevar and Ms Christian not being tasked immediately to carry out this search upon surfacing. Ms Wragge concedes that she did consider this option but determined to put her own diving gear on and to search with Mr Hocevar. Her reasons being that Ms Christian was relatively inexperienced and she did not want Mr Hocevar searching alone. Given her responsibility for the group and the circumstances at the time I agree with the findings of the investigation that although in retrospect immediate action may have led to a different outcome there was no clear probability of this and Ms Wragge's actions were reasonable in the circumstances as she knew them at the time.

Certain items of the oxygen delivery system on board the "Kahala" were also missing, which meant that expired air rather than medical oxygen had to be used during the resuscitation attempts. This was an oversight by Ms Wragge whose responsibility it was to ensure all safety and emergency equipment was on board. However, once again the investigation does not indicate that the inability to use oxygen had a material bearing upon the survival prospect of Ms Rosen.

The Forensic Pathologist, Dr C Lawrence who conducted the autopsy considered a number of conditions that may have led to Ms Rosen's death but concluded that the death was as a result of drowning. I note the following physical findings which are of particular relevance:

•  Profound congestion around both eyes with some petechiae.
  
• There are petechiae on the conjunctivae. On the left eye particularly, the area is oval in shape and suggests a degree of  mask squeeze.
  
• The left eardrum is perforated and there is haemorrhage behind the eardrum.
  
• CT scan examination reveals changes in the lungs possibly consistent with pulmonary oedema or drowning. There is no significant air in the heart. There are small air bubbles in the right ventricle but no air in the left ventricle. No gas is seen in the liver but some gas in the aorta and cerebral veins.
  
• Large amount of heavily blood stained pulmonary oedema fluid in the upper airways. 

Dr Lawrence considered cerebral arterial gas embolism as a possible explanation given an initial history provided to him that there was a rapid ascent to the surface by Ms Rosen followed by loss of consciousness and sinking to the bottom. Although such a history suggested pulmonary barotrauma/cerebral arterial gas embolism (PBT/CAGE) only a small amount of gas was detected on CT scans and dissection and the autopsy appearances did not suggest to Dr Lawrence that PBT/CAGE was an explanation in this case. There was consideration of diver's pulmonary oedema. This condition would fit the appearance of the lungs and is known to be more common in cold water. However, Dr Lawrence concludes that:

"…there is no history of previous similar episodes, the condition cannot be distinguished from drowning by autopsy alone." 

He stated that he would be reluctant to diagnose the condition without a history that Ms Rosen had experienced previous episodes.

Dr Lawrence was provided with more detailed history as to the last observation of Ms Rosen given by Ms Wragge which described her as facing away and that then "the top of her head disappeared under the water. There were bubbles coming up around her face." The description given earlier of Ms Rosen gesturing for a pick up and of not giving any indication of concern at that time was, in Dr Lawrence's opinion, less suggestive of PBT/CAGE.

The remaining findings of note are those of mask squeeze and ruptured eardrum which, together with the finding of Ms Rosen's BCD empty of air, are suggestive of a rapid final descent. By way of explanation "mask squeeze" is described as phenomenon whereby a pressure gradient develops between the pressure inside the diving mask and the external water pressure. The result of this, if accompanied by an inability to equalise the pressure (usually due to there being no air in the lungs available to be drawn out through the nose), is swelling and haemorrhaging around the eyes and ocular protrusion. This phenomenon would be consistent with the initial observations of Ms Rosen and the post-mortem findings concerning her eyes.

Unfortunately the investigation leaves unanswered some aspects leading up to this tragic outcome. However, based upon the evidence to hand and taking into account the opinion provided by the investigating police officers I conclude as follows:

• Ms Rosen had overcome her initial concerns and anxiety and was comfortable and enjoying the dive when last seen by her dive partners.
  
• It is doubtful that without some sudden incident or occurrence she would have surfaced without notifying her dive partners, this fact and the very short period from when she was last seen is suggestive that her ascent was unintentional and perhaps due to improperly operating her BCD. I consider the alternate scenario that she deliberately surfaced due to perhaps losing contact with her dive partners or due to some issue that had arisen for her is perhaps less likely given the positive manner in which the dive was proceeding at that time and the short time lapse. However the possibility of some event perhaps initiating her anxiety again remains open.
  
• Having arrived at the surface Ms Rosen was able to attract the attention of Ms Wragge and, at some stage, has called out to her which means that her air regulator mouth piece was, at least at that time, out of her mouth. Apparently she was buoyant at this time as Ms Wragge states that her BCD was inflated and that Ms Rosen showed no signs of distress.
  
• Ms Wragge has then taken steps to move the boat to Ms Rosen's location to collect her but whilst this was occurring Ms Rosen has once again descended. There is no clear indication of whether this was intentional or unintentional. The observations made by Ms Wragge of Ms Rosen apparently looking for other divers from the surface and then descending is suggestive that she may have located them and taken steps to re-join them.
  
• However, I am satisfied that her descent at this time was uncontrolled, her BCD was found with no air in it and therefore it provided no positive buoyancy. The only explanation for the lack of air in the BCD is that she has dumped the air herself by activating the valve system whether intentionally or unintentionally. This may have occurred on the surface causing her to descend without the opportunity to replace her regulator mouth piece or it may have occurred during the descent whereby she was unable to equalise, has thereby suffered pain and eardrum rupture which may have led to a panic and in some way she has lost her mouth piece. Both of these scenarios are possible, they are consistent with the known facts and both would result in the drowning as detailed.

Comments and Recommendations:

I have decided not to hold a public inquest into this death because my investigation has sufficiently disclosed the deceased's identity, the time, place, relevant circumstances concerning how her death occurred, and the particulars needed to register the death under the Births, Deaths & Marriages Registration Act 1999. I do not consider that the holding of a public inquest is likely to elicit any important additional information further to that disclosed by the investigation conducted by me.

At the conclusion of this investigation I am left with two matters of concern given the possibility that they may have played a part in this tragic accident.

The first is the apparent level of anxiety displayed by Ms Rosen during the period leading up to her initial descent. It is, of course, a personal decision by any person as to whether or not they wish to proceed with an activity. There is nothing to suggest that the wetsuit worn by Ms Rosen was too tight so as to compromise her breathing or create a risk to her. She was clearly not used to wearing a cold water suit but apparently was able to relax and adjust to this given time. Ms Rosen was provided with reassurance and information by the others involved and I accept that although she may have perhaps remained nervous or apprehensive, her mental state was not such that she should not have taken part in the dive. It was for her to make that decision and there is no evidence of any pressure applied by Ms Wragge or the others obliging her to act against her own wishes. There is no evidence that her emotional state was such that Ms Wragge or the others involved ought to have acted in an endeavour to dissuade her from undertaking this dive.

There are some indications that Ms Rosen's difficulties may have had something to do with her intentional or unintentional operation of her BCD. Ms Wragge instructed both Ms Rosen and Ms Christian in the use of this device; however following this it is noted that Ms Rosen took the opportunity to have Ms Wragge confirm the operation of the device with her prior to Ms Rosen entering the water. She then was able to operate the device whilst testing her buoyancy and for the purpose of laying on her back whilst being reassured by Ms Wragge prior to her initial descent. These examples illustrate that she had, in fact, correctly operated the device. However, circumstances suggest she may have inappropriately operated the device causing her initial ascent and that this also occurred upon her terminal descent. I am unable to determine if and why this occurred. The circumstances, however, do highlight the care and time that needs to be taken by those undertaking diving and also those operating charters for that purpose, to ensure that there is a clear understanding and knowledge as to the use of all diving equipment, especially any equipment which is of a type which a participant has little experience.

I conclude this matter by conveying my sincere condolences to the family of Ms Rosen.

 

DATED: 30 May 2014 at Hobart in the State of Tasmania.

 

Stephen Raymond Carey
CORONER