Finlayson, Eric Davis
Deceased
Eric Davis Finlayson
Demographics
68y, male
Date of death
2012-10-09
Finding date
2017-11-27
Cause of death
drowning against a background of cardiomegaly and severe coronary artery calcific atherosclerosis
AI-generated summary
Eric Finlayson, a 68-year-old UK tourist, died by drowning on 9 October 2012 while snorkelling at Michaelmas Cay on the Great Barrier Reef. He had undiagnosed cardiomegaly and severe coronary atherosclerosis. The coroner identified multiple missed opportunities in safety management by Voyager Australia: failure to conduct a snorkeller risk assessment despite fitting the profile of at-risk (older male, international visitor); lack of identification and control measures for at-risk snorkellers; inadequate lookout training and scanning protocols; poor group management with insufficient supervision of individual snorkellers; and fragmentation of critical safety roles among undertrained crew. The lookout on the Cay was a 19-year-old trainee without first aid or CPR training. While CPR was eventually performed and was effective, there were delays in accessing emergency equipment and communications. The coroner found extensive deficiencies in Voyager's written procedures, training documentation, supervision frameworks, and auditing systems compared to available WHSQ guidance materials. The operator resisted recommendations for dedicated supervisory roles, claiming small operator constraints, despite having access to comprehensive published safety resources.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- undiagnosed cardiac condition (enlarged heart, narrowed coronary arteries)
- failure to conduct snorkeller risk assessment despite fitting at-risk profile
- failure to identify deceased as at-risk snorkeller requiring additional control measures
- inadequate training of lookout personnel in scanning techniques and recognition of distress
- fragmentation of safety roles among undertrained crew
- lack of dedicated snorkelling supervisor role
- insufficient direct supervision of deceased during snorkelling
- deceased not required to wear wet suit despite offering
- deceased not participating in guided group tour
- inadequate documentation of safety procedures
- inadequate training and assessment records for crew
- limited or delayed initial CPR support due to shock of untrained staff
- delays in retrieving emergency equipment from vessel
Coroner's recommendations
- Voyager conduct a major review of its procedures, training, supervision and auditing relevant to the manner in which it conducts snorkelling activities
- Workplace Health and Safety Queensland conduct an audit of snorkelling activities conducted by Voyager and report to the Coroners Court on its progress with any independent expert review as well as implementation of recommendations from the Coxon report
Full text
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