Coronial
QLDother

Dell, Maren Lyndsey

Deceased

Maren Lyndsey Dell

Demographics

23y, female

Coroner

Lock

Date of death

2003-05-30

Finding date

2005-10-12

Cause of death

Pulmonary barotrauma due to or as a consequence of a scuba diving accident

AI-generated summary

Maren Lyndsey Dell, 23, died during a resort dive at Agincourt Reef from pulmonary barotrauma caused by rapid ascent from 9 metres. She panicked when unable to clear water from her mask and ascended quickly without expelling sufficient air, leading to arterial gas embolism and cerebral artery gas embolism causing sudden unconsciousness. Medical experts concluded the cause as pulmonary barotrauma rather than drowning. While supervision was adequate and training materials complied with regulations, the coroner found that Ms Dell's visible nervousness and difficulty with basic skills suggested she should not have been cleared to dive. Key clinical lesson: instructors must be empowered to prohibit nervous or struggling novice divers from participating, and training materials should emphasise dangers of rapid ascent regardless of breathing technique. The 2005 Code of Practice was criticised for removing emphasis on instructor decision-making regarding diver competency.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicineoccupational and environmental healthpathologyrespiratory medicinediving medicine

Error types

systemdelay

Drugs involved

epinephrine

Clinical conditions

pulmonary barotraumaarterial gas embolismcerebral artery gas embolismacute hypoxiapaniccardiopulmonary arrest

Procedures

scuba divingmask clearingregulator removal and replacementdescent and ascent procedures

Contributing factors

  • Rapid ascent from 9 metres without expelling sufficient air
  • Panic in response to water entering mask during descent
  • Inability to clear mask underwater despite training
  • Insufficient assessment of diver nervousness and competency before dive
  • Training materials did not adequately emphasise dangers of rapid ascent
  • Instructor failed to prohibit or defer dive despite visible signs of nervousness and anxiety

Coroner's recommendations

  1. The Recreational Diving Industry, in conjunction with the Division of Workplace Health and Safety, should review the training materials and programs used for training resort divers to ensure they meet best practice standards
  2. Training materials should include clear advice to novice and resort divers regarding dangers of diving generally, and specifically the dangers of rapid ascent from any depth
  3. Review training programs for instructors to ensure they recognise factors causing panic in divers and are able to make decisions minimising risk of injury or death, including decisions to provide more training, prohibit the dive, or cut short a dive
  4. Industry should strictly, zealously and conservatively abide by published safety standards
  5. Emphasis should be placed on the difficult task of instructors not only advising divers not to dive but actually prohibiting dives when appropriate
Full text
Official source Archived copy

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