Trott, Leila Michelle
Deceased
Leila Michelle Trott
Demographics
38y, female
Date of death
2016-04-06
Finding date
2017-03-16
Cause of death
Drowning/Immersion due to coronary artery atheroma
AI-generated summary
Leila Michelle Trott, a 38-year-old experienced skipper and dive instructor, drowned after swimming approximately 400 metres to retrieve a drifted tender vessel off Green Island, Cairns. Unbeknownst to her, she had severe coronary artery disease with greater than 75% narrowing of the left anterior descending artery. While swimming, she likely suffered a cardiac arrhythmia secondary to exertion and stress, became unconscious, and drowned. The coroner found her employer had taken reasonable safety precautions and the emergency response was appropriate. However, the inquest highlighted failures in inter-agency communication between Workplace Health and Safety Queensland, Maritime Safety Queensland, and Australian Maritime Safety Authority. Key lessons include: implementing additional safety measures for tender retrieval (secondary securing lines, clear protocols), establishing mandatory inter-agency communication procedures for marine incidents, and addressing perceived pressure in male-dominated industries. The unavailability of the aeromedical helicopter did not impact outcome given the prolonged time in water and cardiac nature of the event.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- Severe coronary artery narrowing (>75% left anterior descending artery) unknown to deceased
- Cardiac arrhythmia likely induced by exertion and stress of swimming
- Tender vessel came adrift from main vessel
- Deceased chose to swim to retrieve tender rather than call for assistance from nearby vessels
- Delay in PAN-PAN emergency call (40-50 minutes after disappearance)
- Lookout left his position when deceased was 50 metres from destination
- Aeromedical helicopter unavailable due to scheduled maintenance
Coroner's recommendations
- WHSQ, MSQ, AMSA and QPS should consider closer inter-agency cooperation and review the circumstances of this death and the involvement of their respective agencies
- Agencies should determine whether further action should be taken to update any existing Memoranda of Understanding
- Agencies should provide further training to their staff in relation to their operation and jurisdictional overlap
- Updated MOUs should take into account the Marine Safety (Domestic Commercial Vessel) National Law Act 2012 and the relationship between AMSA and MSQ
Full text
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