Coroner's Finding: HUMBERSTONE Rex Alexander John

Contributing factors

• severe obesity
• emphysema with lung bullae
• coronary atheroma with ischaemic cardiac fibrosis
• enlarged heart (cardiomegaly)
• tight-fitting wetsuit causing chest compression
• exceptionally heavy weight belt with shoulder straps preventing quick release
• faulty buoyancy control device
• lack of recent diving medical examination
• fatigue and hypoxia during exertion in water

Coroner's recommendations

1. All persons engaged in recreational underwater diving should undergo examination by a registered general medical practitioner trained in hyperbaric medicine regularly, preferably annually but not less frequently than every two years
2. Medical practitioners should decline to conduct diving examinations unless they are appropriately qualified to do so
3. Medical practitioners conducting diving examinations should, if not the subject's regular practitioner, require a referral letter detailing the subject's medical history
4. Medical practitioners should warn subjects that diving is potentially lethal with certain medical conditions and that absolute honesty in providing medical history is required
5. If any doubt exists 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 fitness to dive
6. The recreational diving industry should conduct an awareness campaign about dangers of diving with certain medical conditions, the need for regular medical examinations at least every two years, the need for absolute honesty during examinations, and the responsibility of divers to ensure personal fitness to dive