Record of Investigation into Death (Without Inquest)
Coroners Act 1995
Coroners Rules 2006
Rule 11
I, Stephen Raymond Carey, Coroner, having investigated the death of
Rodney Peter HOWELL
WITHOUT HOLDING AN INQUEST
Find :
(a) The identity of the deceased is Rodney Peter Howell (Mr Howell) who died on 25 July 2010 at D’entrecasteaux Channel, Woodbridge.
(b) Mr Howell was born on 26 July 1961 and aged 48 years.
(c) Mr Howell was married and was a business owner at the time of his death.
(d) Mr Howell died as a result of cerebral arterial gas embolism due to pulmonary barotrauma. Contributing factors may have been a history of ventricular tachycardia and tight stenosis of very small LAD origin septal vessel.
Circumstances Surrounding the Death :
Mr Howell had been married to Vera Howell for 23 years. They had two children, Timothy aged 21 and James aged 16. Mr Howell worked as a mechanic and in October 1990 they opened their own business, Howell Automotive, located in Moonah. Mrs Howell worked in the office and Mr Howell managed the work shop. Mrs Howell notes that Mr Howell was a “well liked and respected man with many friends and many interests”. He “loved his work” and “was quite healthy for his age” .
Mr Howell was an avid fisherman and scallop diver and according to Mrs Howell had been diving for many years. During the week leading up to his death Mr Howell organised a scallop diving trip with friends, Mr Turvey and Mr Moody. They planned to leave early on Sunday morning 25 July and return by 2.00pm the same day.
Mr Howell picked up Mr Moody and Mr Turvey and they launched the boat at the Woodbridge Ramp near Peppermint Bay at approximately 9.30am. The boat belonged to Mr Turvey and was a 7 metre aluminium half-cab vessel. The boat was well maintained and fully equipped. They dropped anchor on the eastern side of Green Island in approximately 6 to 8 metres of water. Mr Moody used his own scuba equipment for the first dive and noted that Mr Howell planned to dive on Hookah equipment (this is an air compressor powered by a petrol motor and remains on the boat feeding air from the compressor via an air hose and regulator).
The Hookah was built and assembled by Mr Turvey approximately four to five years ago.
Mr Moody states that Mr Howell was “…wearing a wet suit, 5mm in thickness, a wetsuit vest including a hood which was also 3mm thick, set of fins, weight belt, catch bag, gloves; a mask ”. He was not sure if he had a snorkel. Mr Moody further states “The Hookah gear which is the hose and regulator is fed around your body so it cannot be easily removed. It goes down through the weight belt at the back, between your legs and up through the front of the weight belt and over the left hand shoulder and the back of the neck and then attached to the regulator and you then place the regulator into your mouth”.
The first dive was uneventful. Following the first dive they had collected approximately 35 scallops between them and decided to move closer to Bruny Island to search for larger commercial scallops. Mr Moody noted that sea conditions were calm, it was sunny and there was no breeze. As the divers prepared for the second dive Mr Moody noted that he did not have sufficient air in his scuba tank so decided to use the Hookah compressor via a second air hose and regulator.
Mr Howell entered the water first on the second occasion. Mr Moody and Mr Howell then swam together for about 5 to 10 minutes and when the sea bed became stirred up they separated. When Mr Moody reached his bag limit after about 15 minutes of diving he began to ascend and surfaced approximately 20 to 30 metres from the port side of the boat. He did not see any seals or sharks in the area. He reached the boat and handed Mr Turvey his catch bag and weight belt, and climbed into the vessel. He then noticed Mr Howell on the surface of the water about 40 metres off the starboard side of the vessel. Mr Moody says “He looked like he was struggling a bit…his head and shoulders were just above the water. He still had his mask on his face and I am not sure whether he had his regulator still in his mouth. He then went back under.”. Mr Howell called out for Mr Moody to help him. Mr Moody put his fins on and swam to him. He states that his swim was a little awkward as he had inflated his dry suit and had not let the air out of it prior to entering the water again and that he deliberately left the air in the suit to assist with buoyancy in the event Mr Howell needed assistance to return to the boat.
When Mr Moody reached the location he had last seen Mr Howell he could not see him. Mr Moody states “The Hookah line was vertical from the bottom of the sea bed and there were no signs of air bubbles”. Mr Moody yelled to Mr Turvey to commence hauling Mr Howell in by the Hookah line. Mr Moody swam back to the boat and started to pull on the line while he was still in the water. Mr Howell surfaced facing away from him and he could see that his mask was still on and it was apparent that he was not breathing. Mr Moody estimates that “This was probably about one and a half minutes since we had seen him at the surface of the water when he had asked for help”.
Mr Turvey did not get into the water. Mr Moody held Mr Howell from behind and Mr Turvey reached over the rear of the boat and pulled Mr Howell’s mask off. Mr Moody noted that there was a small amount of blood in the mask and there may have been some on Mr Howell’s face. Mr Moody removed Mr Howell’s weight belt and let this drop to the sea bed. He attempted to wake him without success. Mr Turvey attempted to get a breath into Mr Howell’s mouth while Mr Moody held him on the surface but there was no response.
Mr Turvey then called for assistance over the marine radio and let off a flare.
Mr Lindsay Sward together with his family were on board his vessel the “Tamar Star” near Stockyard Point in Missionary Bay in the D’Entrecasteaux Channel on 25 July 2010. They had been diving for scallops and were returning towards Kettering when they saw an orange distress flare. They headed in the direction of the flare and pulled alongside the vessel where they could see a diver in the water. He had a wetsuit on, no mask or snorkel and no regulator or dive hose connected to him. Mr Sward noted another diver in the water with him trying to get him up and into the boat. Mr Sward jumped into the water and swam to assist. He could see that Mr Howell was unconscious. They managed to get Mr Howell onto the boat and commenced CPR.
Tasmania Police performing duties on board Police Vessel “Swift” in the D’Entrecasteaux Channel received a Mayday call at approximately 11.30am on Sunday 25 July 2010. The caller identified an unconscious diver and stated their vessel location was near the floating fish farm near Satellite Island. Tasmania Police drove to the Police Vessel “Vigilant” to obtain additional resources and equipment. “Swift” is a six metre twin outboard rigid inflatable and was the quicker response vessel. Officers proceeded to the advised location however were unable to locate a vessel. They attempted to obtain a response over the radio and received a reply at approximately 11.50am which provided a revised location of “near the floating fish farm near Missionary Bay”. An orange flare was let off to signify the vessel’s location. The vessel proceeded to the Woodbridge Jetty with the Police Vessel “Swift” following. Officers boarded the vessel and noted an unconscious male person lying on the deck. Officers took over resuscitation efforts and continued until Ambulance officers attended some five minutes later. Approximately ten minutes after arrival of Ambulance officers resuscitation efforts were ceased and Mr Howell was declared deceased at 12.30pm.
Mr Moody states that “At no time did I smell or taste any carbon monoxide in my regulator when I was diving with the Hookah. I felt that I was getting adequate air through the regulator…”. He further states that “…At no time did I see Rodney trying to adjust his regulator or appearing uncomfortable due to lack of air or a problem with the regulator that he was using. He appeared comfortable and the conditions were perfect.”. In Mr Moody’s opinion “Rodney was an experienced Diver and he would have known that it was unsafe to surface quickly. He was a cautious diver and would normally stay at safer depths than me…”.
C Van den Broek, Facility Manager, Diving and Hyperbaric Medicine Unit, Royal Hobart Hospital carried out an inspection of the diving equipment and makes the following observations:
- “A significant fuel leak was present on the compressor which caused a constant fuel odour around the equipment.
- The Air tests conducted on the compressor indicated a high levels of CO and water vapour present in the air reservoir.
- No inlet filter was present.
- The filtration system on the compressor utilised a standard plastic water filter, which would have been ineffective as an air filter.
- There was a supply reduction from ¾ inch to ¼ inch prior to breathing hose split out of the water filter, this would restrict the supply to both divers.
- The small bridging hose indicated signs of being kinked which would have led to a reduction in the air supplied to the divers.
- A purge by the diver on the surface would have reduced the diver at depth air supply significantly.
- No one way valves were present on the down stream side of the compressor (preferably at the divers end); these are used to protect each diver from a negative pressure in their supply hose should the hose be severed or open at the surface.
- There is only minimum spacing between the air inlet and motor exhaust. The downward curve on the inlet would have created a preferential to draw air from near the exhaust.”
Dr Christopher Lawrence, State Forensic Pathologist carried out the autopsy of Mr Howell. He reports:
“Autopsy reveals changes consistent with a cerebral arterial gas embolism with gas in the heart, the aorta, the brain and the vessels. There is no ischaemic heart disease. There is no strong evidence of drowning. The appearances favour strongly a cerebral arterial gas embolism. This occurs when a diver inhales compressed air and then ascends rapidly without breathing out causing rupture of either the airways and vessels in either the lungs or the mediastinum causing gas to enter the vascular system and embolising to the brain. It is a much feared complication of diving. It only occurs after a rapid ascent if the person has not breathed out…… It is possible that a cardiac arrhythmia could have caused him to become acutely unwell and ascend too rapidly. It is also possible that that cardiac arrhythmia could have caused unconsciousness and drowning, however this would not account for the appearances of gas in the heart, unless that is entirely due to post-mortem off-gassing.”
As regards the contribution of pre-existing cardiac conditions the pathologist had the benefit of the records of Dr D Kilpatrick, a specialist cardiologist, who had treated Mr Howell over the period December 2006 through until June 2008. In summary, these records evidence;
- History of palpations and dizzy spells.
- History of angina.
- Cardiac catheter showing type stenosis of very small LAD origin septal vessel.
- Exercise Sestami scan showing area of ischaemia.
- Holter monitor showing paroxysmal atrial tachycardia (PAT) and ventricular tachycardia (VT).
- Questioned right ventricular outflow tract tachycardia.
Sergeant Paul Steane from Search & Rescue Services, an experienced member of Marine Services, has commented that he agrees with Dr Lawrence in that the most likely cause was “inadvertent ascent”.
Miriam Rae Connor, Forensic Science Service Tasmania carried out alcohol, carboxhyaemoglobin and comprehensive drug analyses with negative results.
Comments :
I am satisfied that a full and detailed investigation has been undertaken in relation to the death of Mr Howell and that there are no suspicious circumstances.
I find that Mr Howell died as a result of cerebral arterial gas embolism due to pulmonary barotrauma. I accept that contributing factors may have been a history of ventricular tachycardia and tight stenosis of very small LAD origin septal vessel.
I accept and adopt the findings of Dr Lawrence that Mr Howell’s death most likely occurred following Mr Howell inhaling compressed air and ascending rapidly without breathing out, causing a rupture of either the airways or vessels in either the lungs or the mediastinum which caused gas to enter the vascular system and embolising to Mr Howell’s brain.
There could be many reasons why Mr Howell ascended in the manner in which he did. Among those possibilities are that Mr Moody, the first diver to surface, may have purged his regulator causing a brief loss of air supply to Mr Howell, he may have succumbed to cold causing him to become unwell or as he had a history of cardiac problems detailed above, he may have suffered a cardiac arrhythmia that caused him to become acutely unwell.
I am unable to determine the reason why Mr Howell ascended rapidly and accept that as an experienced diver he would have been aware of the risk of failing to breathe out during an ascent.
In the opinion of Sergeant Steane, an experienced police diver, the dive practices of the party appeared to be “reasonable for a recreational crew” and although the Hookah equipment was not perfect it did not represent as a death trap. The defects with the Hookah equipment are outlined herein and it is of concern that these deficits were not known to or able to be recognised by the users of the machinery. I am not aware of whether the number of instances of diving accidents associated with the use of Hookah equipment warrants the cost associated with a formal regulatory system, but at the very least there needs to be readily available public information stressing the need for professional assessment and periodic servicing of such equipment. Such information needs to stress that diving, especially in deeper water, is an hazardous activity and any equipment faults or shortcomings would accentuate the risks associated with this activity.
I am unable to say upon the information available whether or not the medical advisers of Mr Howell were aware of his recreational activities, in particular diving. I would have thought however that any public information that is provided about diving should address the risk factors and the need to ensure that those involved in the activity have sought advice from their doctor as to whether there is anything concerning that person’s health that either precludes them from engaging in diving or at the very least gives that person an understanding of any increased risk that they need to accept should they continue that activity.
I wish to conclude by conveying my sincere condolences to the family of Mr Howell.
DATED: 20 day of September 2011 at Hobart in the State of Tasmania.