Non-inquest findings into the death of Robert Norvell Brown
Deceased
Robert Norvell Brown
Demographics
59y, male
Date of death
2023-05-05
Finding date
2026-09-14
Cause of death
Multiorgan failure due to cardiorespiratory arrest of unknown aetiology (SCUBA diving) with hypertension and coronary atherosclerosis recorded as contributing conditions
AI-generated summary
Robert Norvell Brown, 59, an experienced recreational scuba diver with over 500 dives, suffered acute cardiorespiratory arrest during a dive at the ex-HMAS Brisbane wreck site off the Sunshine Coast on 5 May 2023. While at 14-15 metres depth, he became acutely distressed and panicked, was assisted to the surface by dive masters, and entered cardiac arrest. Immediate CPR, oxygen, and prolonged advanced resuscitation including intubation and bilateral thoracostomies achieved return of spontaneous circulation, but he suffered severe hypoxic-ischaemic brain injury and multiorgan failure, dying the same day. Comprehensive multidisciplinary investigations by Queensland Police, Workplace Health and Safety Queensland, Queensland Ambulance Service, and the Dive and Snorkelling Death Review Panel excluded equipment failure, intoxication, criminal conduct, negligence, and safety breaches. The precise medical trigger remained uncertain; the Dive Panel identified immersion pulmonary oedema as most likely given his hypertension, coronary atherosclerosis, and beta-blocker therapy. No person or organisation contributed to the death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Clinical conditions
Contributing factors
- hypertension
- coronary atherosclerosis
- chronic cardiovascular disease
- atenolol therapy
- exertion in diving environment
- possible immersion pulmonary oedema
- possible decompression illness
- possible pulmonary barotrauma
Coroner's recommendations
- Establish procedures for safe and timely recall of divers when a medical emergency occurs
- Review whether a dive supervisor should accompany a distressed diver to the surface
- Develop standardised assistance call procedures between vessels operating at popular dive sites
- Establish site-specific retrieval and recovery arrangements for major dive locations
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