Coroner's Finding: BARRINGTON Jennifer Lee

Contributing factors

• history of pneumothorax with pleural adhesions predisposing to pulmonary vein rupture
• Eustachian tube dysfunction
• false denial of medical history to diving medical examiner
• inadequate diving medical examination by non-specialist physician
• buddy system failure - diver allowed to ascend alone despite stress and anxiety indicators
• rapid air consumption consistent with anxiety underwater
• possible acute vertigo attack during ascent

Coroner's recommendations

1. All persons engaged in recreational underwater diving should undergo examination by a registered general medical practitioner trained in hyperbaric medicine on a regular basis, preferably annually but not less frequently than every two years
2. Medical practitioners should decline to conduct diving medical examinations unless they are appropriately qualified to do so
3. Medical practitioners conducting diving examinations, if not the subject's regular GP, should require the subject to produce a referral letter detailing their medical history
4. Medical practitioners conducting diving examinations should warn the subject that diving is a potentially lethal activity if undertaken by persons with certain medical conditions, and that absolute honesty in providing background medical history is essential
5. If there is any doubt about the subject's health, the medical practitioner should arrange follow-up tests such as chest X-rays or hypertonic saline tests before passing the subject as fit to dive; any doubt should be resolved against passing the subject as fit until follow-up tests demonstrate fitness
6. The recreational diving industry should conduct an awareness campaign about the dangers of diving with certain medical conditions, the need for regular medical examinations at least every two years, the need for absolute honesty during such examinations, and the responsibility divers have to both themselves and their diving colleagues to ensure fitness to dive