RECORD OF INVESTIGATION INTO DEATH
Coroners Act 1995
Coroners Rules 2006
I, Stephen Raymond Carey, Coroner, having investigated the death of
have decided not to hold a public inquest hearing into his death because my investigations have sufficiently disclosed the identity of the deceased person, the time, place, cause of death, relevant circumstances concerning how the death occurred and the particulars to register the death under the Births, Deaths and Marriages Registration Act 1999. I do not consider that the holding of a public inquest hearing would elicit any information further to that disclosed by the investigations conducted by me.
(a) The deceased is David Perry ("Mr Perry") who died at Eaglehawk Neck in Tasmania on 29 January 2012.
(b) Mr Perry was born on 25 June 1953 and was aged 58 years at the date of his death.
(c) Mr Perry was employed as a registered nurse.
(d) The cause of Mr Perry's death is recorded as unexpected death whilst scuba diving. Probable significant contributing factors were noted as obesity and atrial fibrillation.
Circumstances surrounding the Death:
Mr Perry had previous experience diving but had not dived for approximately 20 years. He has made the decision to recommence this activity and commenced diving again approximately 1 month prior to his death. Mr Perry has conducted a number of informal dives since November/December 2011 with staff of "Go Dive", a dive instruction company based in Launceston. On 27 January 2012, Mr Perry has attended Eaglehawk Neck where "Go Dive" has an accommodation lodge where he stayed with others to complete an advanced dive course. Prior to commencing this course, Mr Perry was required to sign a medical questionnaire form and also a waiver of liability for "Go Dive" and its employees. The medical questionnaire is endorsed with emblems of the Recreational Scuba Training Council and the Undersea and Hyperbaric Medical Society. The medical questionnaire was set up in such a way that a positive answer to any of the questions would require a medical examination of the student prior to completing any scuba diving training. Mr Perry answered "yes" to the question "Are you presently taking prescription medication?" Notwithstanding this, he had not undergone a medical examination prior to conducting dives on 28 January 2012 and on 29 January 2012. The medical questionnaire was completed by Mr Perry on 27 January 2012.
Mr Perry undertook a buoyancy dive on Saturday, 28 January 2012, this dive lasted for a period of 35 minutes. He then performed a navigation dive which lasted 36 minutes and was completed at a depth of 6.5m. He then had a final dive on that day which was conducted as a night dive at approximately 9:00pm. At the conclusion of those three dives, Mr Perry did not raise any medical issues with other students, or his instructors employed by "Go Dive".
On Sunday, 29 January 2012, Mr Perry was to undertake a deep dive which utilised enriched air using a 31% oxygen enriched mixture with the intention to dive to 30m.
At 8:00am, Mr Perry and 8 other persons had left the Pirates Bay jetty and travelled to Deep Glen Bay which is located approximately 4km north of Pirates Bay. The group has descended to a level of 30m undertaking stops and checks during the descent. The group consisted of a lead diver, Ms Sharon Fitzpatrick, who was a PADI (Professional Association of Dive Instructors) staff instructor employed by "Go Dive", two experienced divers acting as dive masters (Mr Nicholas Livingstone and Ms Breyana Acworth) and students attending their advanced open water course.
The group have gradually descended, stopping at the 10m mark to conduct checks to ensure all participants were coping and not experiencing any difficulties.
After completing the requirements of the course at the 30m mark, the group have commenced to slowly ascend as they followed the ocean floor towards the shore. Ms Acworth has drawn Mr Livingstone's attention to a diver dropping back at the rear of the group and losing contact with his dive "buddy". Mr Livingstone has thereupon gone back to "buddy up" with this diver (Mr Perry) and Ms Acworth has buddied up with the other diver and re-joined the main group. Mr Perry has signalled to Mr Livingstone and Ms Acworth that something was not right. This is the first indication that he had given at any time throughout this dive that he was in any difficulty or that anything was wrong. Mr Perry conveyed that he was out of air; Mr Livingstone commenced to unclip a spare cylinder that he was carrying and signalled that he wanted to look at Mr Perry's pressure gauge. When he did, he noted that Mr Perry had approximately half a tank remaining, Mr Perry however indicated he wished to ascend so Mr Livingstone deployed a safety line and surface marker buoy which is a safety device which is used to indicate to the support boat that divers are surfacing.
At this point Mr Livingstone and Mr Perry were at about the 10-12m level and after deployment of the surface marker buoy, Mr Livingstone has indicated to Mr Perry to swim towards him and to hold on to the safety line. Mr Perry began to swim to him and was approximately 5-8m away when Mr Livingstone momentarily looked down to start winding his safety line reel which would start winding them up the safety line. At this stage they were at approximately 10m and it was 29 minutes into the dive.
When Mr Livingstone looked back, he noted that Mr Perry was floating towards the surface and Mr Perry indicated he was having trouble with his buoyancy. Mr Livingstone signalled to Mr Perry to dump air from his buoyancy compensatory device in order to slow his ascent. Mr Perry appeared to be trying to do this but he continued to ascend and Mr Livingstone lost sight of him. Mr Livingstone continued his ascent to the 5m mark which is the designated safety stop where you stay for 3 minutes to allow nitrogen to escape your body.
Whilst he was at this point he saw a silhouette of a person on the surface of the water which he presumed to be Mr Perry so he swam along towards him still at the 5m level. He then noticed that this person was face down and he assumed that this was Mr Perry looking down into the water waiting for Mr Livingstone to ascend. This is not an unusual process. Mr Livingstone signalled to him to stay at the surface and not to descend and as Mr Livingstone ascended closer to Mr Perry, he could see that his regulator was not in his mouth. Noting this, Mr Livingstone surfaced as fast as he could. He inflated his buoyancy compensator device and swam towards Mr Perry. He then rolled him clockwise on to his back and held his head out of the water. He could not identify any sign of breathing. There was no movement in Mr Perry's chest. Mr Livingstone forced open Mr Perry's mouth and commenced resuscitation by blowing into his mouth. He yelled out to Mr De Villiers who was driving the support boat whilst he continued to give mouth to mouth resuscitation. He noted that Mr Perry's chest was rising and falling, but there was no movement without the breaths. Mr Livingstone then dropped his diving weights and took the diving gear off Mr Perry.
The support boat arrived and Mr De Villiers, in the boat, and Mr Livingstone in the water, tried to drag Mr Perry into the boat. They were unable to do so due to the weight of Mr Perry (129kg) so whilst Mr Livingstone continued to support Mr Perry in the water, Mr De Villiers has taken the boat to the dive team and retrieved Sharon Fitzpatrick. The three were then able to get Mr Perry out of the water and over the side of the boat. Oxygen was administered together with other CPR endeavours on Mr Perry. Their boat was taken closer to a charter fishing boat in the area who undertook to recover the remaining dive team members whilst the "Go Dive" boat returned to the jetty at Pirates Bay. Also at this time, emergency services had been contacted.
Upon arrival at the jetty at Pirates Bay, volunteer ambulance personnel were in attendance and resuscitation endeavours continued. A short time later paramedics arrived and continued resuscitation attempts which included the administration of adrenaline and the use of a needle decompression in an attempt to release any air that might be trapped in his lungs. These endeavours ceased after a period during which there was not positive response from Mr Perry.
Comments and Recommendations:
The physical and medical condition of Mr Perry raises a clear concern as to whether he was fit enough to conduct this scuba diving training.
A further concern is the applicable process in place by the operator, "Go Dive", to assess whether or not the physical and medical condition of Mr Perry exposed him to material additional risks when undertaking this scuba diving, especially at the increased depth. Mr Perry suffered atrial fibrillation, reflux oesophagitis and obesity (129kg). His treating general practitioner, Dr Archer, advises that he had "a past history of anxiety and depression associated with the breakdown of his marriage several years ago." His atrial fibrillation was apparently first diagnosed on 2 August 2005 and since then there had been four presentations to emergency medical facilities in relation to that condition notwithstanding that he was prescribed medication to control the condition. At Mr Perry's presentation to the Launceston General Hospital on 17 September 2010 for a cardiology review, he was reported as giving a history of suffering episodes of palpitation around twice a month and that these lasted from between 1 and 6 hours. A female friend of Mr Perry's who had, during April 2009 and January 2012, been in a personal relationship with him, describes that:
"He did not take his medication for atrial fibrillation on a regular basis, some days he would take none and on other days he would take several."
Towards the end of 2011, Dr Clarke referred Mr Perry to a heart specialist in Melbourne and as a result it was recommended that he have a pacemaker installed.
He suffered some form of depression as every now and then he would fall apart and "cry in my company".
He took Panadeine Forte for a sore shoulder.
The company conducting the scuba diving course adopted the PADI administrative procedures for granting competencies and qualifications. As part of that it also requires students to complete documents in which they totally release PADI and the operators of the specific dive course from any liability in respect of their training. Also as part of that process, a student is required to complete a medical questionnaire that addresses a number of medical issues which presumably indicate a need for a more specific medical assessment dependent upon a positive answer to any of the questions in that questionnaire. In relation to the questionnaire completed by Mr Perry, the following should be noted:
It was completed by him on 27 January 2012, presumably when he was already in location at the "Go Dive" accommodation lodge and was to commence his training dives the next day.
He answered "Yes" to the question "Are you presently taking prescription medication?" He inaccurately answered the question that being over 45 years of age he stated that he was not currently receiving medical care when in fact he was under active medical treatment for his cardiac condition and reflux oesophagitis.
He (possibly) inaccurately answers "No" to the question "Have you ever had, or do you presently have behavioural health, mental or psychological problems?"
He possibly inaccurately answered "No" to the question "Have you, or have you ever had, back, arm or leg problems following surgery, injury or fracture?"
He (possibly) inaccurately answered incorrectly to the question of whether he had heart disease.
The medical questionnaire makes it very clear that an affirmative answer to any question will require a student to undergo a medical assessment before they continue with the proposed scuba diving training. This obligation was not required of Mr Perry. It is also clear that he inaccurately answered some questions be it deliberately or as a result of misunderstanding the extent of those questions. For example, he clearly had a cardiac condition which properly would have come within the description of "heart disease". He did not volunteer needing pain relief for his shoulder.
My investigations have revealed that there is no mandated Code of Practice controlling scuba diver training in Tasmania. There is an Australian Standard 4005-1 which provides guidance upon the pre-entry requirements and training in scuba diving. The application of this Standard is not mandated in any State as a Code other than Queensland. This Standard, amongst other things, obliges a student to undergo a specific pre-diving medical assessment prior to commencing scuba diving training. I am advised that there is a move by the dive training industry to abandon AS4005-1 in favour of the "International Standards" which do not oblige a medical examination. There is also apparent opposition from the industry concerning any move to mandate the application of AS4005-1. Associate Professor David Smart, Consulting Specialist in Diving and Hyperbaric Medicine at the Royal Hobart Hospital maintains the need to establish as a pre-requisite to undergoing recreation scuba diving, the conduct of a specialist medical examination. He highlights that the South Pacific Underwater Medicine Society favours this together with further medicals should there be a significant change in the person's health status and, in any event, at 5 yearly intervals after a person turns 45 years. As I understand the overall intent of the Australian States subsequent to enacting nationwide consistent occupational health and safety legislation is to issue consistent Codes of Practice in each State which will cover a full range of industries. This process, understandably, gives precedence to those industries that have high numbers of fatalities and injuries. Scuba diving is a very popular activity, both in Tasmania and throughout Australia. A database search of the National Coronial System identifies 67 deaths being reported within Australia and New Zealand between 1 July 2000 and 1 May 2013 (the data from Queensland is from 1 January 2001). Of these reported deaths none are recorded as occurring whilst the person was engaged in formal training or a diving course. This data, however, relates specifically to scuba (self-contained underwater breathing apparatus) diving and does not include those involving the use of an airline Hookah system. There is clearly a divergence of opinion between the scuba diving industry and some areas of medical science as to the need to oblige a person to undergo a specialist medical examination prior to commencing scuba diving. The industry, as I understand it, articulate that a medical questionnaire is suitable as this presumably would highlight whether or not a person had a medical condition or conditions that require further investigation prior to them undergoing scuba diving training. Research conducted by Catherine Meehan and Michael Bennett which was published in an article "Medical Assessment of Fitness to Dive - Comparing a Questionnaire and a Medical Interview - Based Approach" reported in the Diving and Hyperbaric Medicine Journal Vol. 40 No. 3 at pages 119 - 124 disclosed discrepancies between a person¡¦s answers to a pre-dive medical questionnaire and the results of their medical examination. A sample group of 1,000 persons was used to compare the results that they gave to their medical questionnaire as compared to what was found upon a specialist medical examination. Of the group of 1,000, approximately 1% of the diving candidates "passed" the medical questionnaire but were found, on the medical examination, to be "unfit to dive". The authors concluded that:
"The impact on morbidity and mortality remains unknown. Evidence exists both in favour of face to face medical assessment before undertaking scuba training and that such consultations add little to the value of the prospective diver. More work is needed in this area. At this time, we recommend caution before implementing changes to the current system of assessment in Australia, and the inclusion of a valid and meaningful assessment of the impact of any such change."
This issue will obviously be considered by the stakeholders in the future. I recommend that any change, be it to mandate an Australian Standard or, alternatively, to make less restrictive the current Standard, should only occur after thorough and reasoned assessment which includes consideration of the medical, community, participants and industry input. There was obviously a proper basis to justify the issue of AS4005-1 and the onus must be that any change does not materially affect the health risk status of anyone undergoing scuba diver training or as a recreational activity. Such investigation goes far beyond the scope of my investigation into the death of Mr Perry. Although it is highly probable that a pre-dive specialist medical examination may have determined that Mr Perry was not fit to dive, the obligation for such a medical examination in fact existed upon the process that was in use at the time by "Go Dive" based upon the answers Mr Perry provided to the medical questionnaire. "Go Dive" were not applying AS4005-1 but rather the loosely described International Standards that require completion of a pre-dive medical questionnaire. This questionnaire contains the preamble:
"The purpose of this medical questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a pre-existing condition that may affect your safety while diving and you must seek the advice of your physician prior to engaging in dive activities. Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving."
As detailed previously, Mr Perry did provide a positive answer and yet he was permitted to carry on with the dive course. Once again, I must infer that this medical questionnaire was designed and based upon sound medical opinion and that it was unacceptable that the obligation for him to undergo a medical examination would not be enforced by those conducting the activity. In this case there was a form of medical assessment, not as rigorous as AS4005-1 but a procedure nonetheless and it was not complied with. Given the range of medical problems suffered by Mr Perry, it is a possibility that the formal medical examination may not have cleared him for his diving course.
It is incumbent upon organisations and individuals who conduct scuba dive training to do so applying a recognised and accepted industrial standard. "Go Dive" did so in this case using the PADI format and yet they did not comply with those standards. This case highlights the risk of non-compliance and I strongly recommend that all such operators should adopt an accepted and validated industry standard be it based upon AS4005-1 or otherwise and that they comply with such standard. It was clearly unsuitable for Mr Perry to be completing the dive medical questionnaire when, presumably, he was already in location in preparation for the course. This pre-course documentation, if it is to have any proper affect, must be completed before a person commences the scuba diving training when it is possible to delay their attendance at the course until a medical or other issue is addressed.
Save for this failure to comply with their own procedures insofar as the medical pre-dive assessment was concerned, there was nothing arising from my investigation that suggests that the training conducted by "Go Dive" and its employees and agents was other than at an appropriate and acceptable standard.
It is apparent however that Mr Perry's atrial fibrillation combined with his obesity and poor physical fitness would have been contributors to his death. Additionally his inability to cope with the increased respiratory work require whilst diving at deep level because of these pre-existing medical conditions may well have led to his perception that he was out of air. Associate Professor David Smart comments that:
"It is also possible Mr Perry developed scuba diving pulmonary oedema, a potentially fatal condition. Atrial fibrillation and obesity are risk factors for developing scuba diver's pulmonary oedema recently linked to a number of fatalities in Australia, it occurs mostly in divers over the age of 40 with cardiovascular disease who dive in cold water. Post mortem findings did demonstrate a dilated heart and oedema filled in the airways, however this also can be due to drowning."
Mr Perry's treating doctor states he was unaware of Mr Perry's intention to undergo this scuba diving course. He agrees that his atrial fibrillation and obesity were material risk factors. It is therefore unlikely that if Mr Perry was obliged to undergo a medical assessment that he would have been cleared to undertake this training. I highlight to the medical profession these health factors that increase risk to participants engaging in scuba diving and direct them to the website of the South Pacific Underwater Medicine Society that sets out the information they require in advising a patient.
Before I conclude I wish to convey my sincere condolences to the family of Mr Perry.
DATED: 21 day of June 2013.
Stephen Raymond Carey