Broe, Stephen James

Contributing factors

• inadequate dive medical examination failing to investigate obstructive sleep apnoea
• obesity (BMI 34)
• severe obstructive sleep apnoea
• Conn's syndrome with borderline hypertension
• dive medical practitioner failed to make inquiries about sea-sickness medication (Phenytoin)
• dive medical practitioner did not adequately assess risk of pulmonary hypertension from OSA
• physical exertion required to reboard vessel post-dive with 47kg equipment

Coroner's recommendations

1. Review the MOU between Queensland Police Service and WH&SQ to ensure specialist diving units in both agencies are expeditiously notified of all diving deaths, and to involve the Office of the State Coroner to develop procedures for early coroner notification
2. Director Forensic and Scientific Services should develop a protocol for CT scanning of deceased divers in Queensland Health regional hospitals to address inconsistency in access to timely imaging
3. WH&SQ should consider amending the Recreational Technical Diving Code of Practice to provide guidance on preferable methods for technical divers to reboard the dive platform and highlight physical exertion following a dive as a risk factor for onset of decompression illness
4. Joint Standards Australia/New Zealand Committees overseeing relevant standards for recreational and occupational diving should review the dive medical forms in light of evidence from this inquest, with explicit consideration of the role and responsibility of the medical examiner