Coroner's Finding: KINNEAR Neville Arthur
Deceased
Neville Arthur Kinnear
Demographics
58y, male
Date of death
2001-04-15
Finding date
2004-04-06
Cause of death
salt water drowning following air embolism due to ascent barotrauma
AI-generated summary
A 58-year-old male experienced cerebral arterial gas embolism (CAGE) during recreational scuba diving ascent, resulting in drowning. Pleural adhesions from prior motor vehicle accident restricted lung expansion during ascent, causing lung rupture and air entry into pulmonary veins. Contributing factors included obesity (BMI 32), poor cardiovascular fitness, tight wetsuit, and possible dehydration. The coroner found this death preventable, emphasising that a pre-dive medical examination by a practitioner trained in diving medicine would have identified pleural adhesions on chest X-ray and contraindicated diving. Key lessons: recreational divers require regular medical assessment by diving medicine specialists; disclosure of medical history is critical; fitness assessment must be thorough before clearance to dive.
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Specialties
Error types
Clinical conditions
Contributing factors
- pleural adhesions from prior motor vehicle accident restricting lung expansion
- obesity with BMI 32
- poor cardiovascular fitness
- cardiomegaly
- tight wetsuit restricting breathing
- possible dehydration
- possible gastric reflux
- lack of recent diving experience
- inadequate pre-dive medical examination
Coroner's recommendations
- All persons engaged in recreational underwater diving should undergo an 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.
- Medical practitioners should decline to conduct diving examinations unless they are appropriately qualified to do so.
- Medical practitioners conducting such examinations should, if they are not the subject's regular medical practitioner, require the subject to produce a referral letter detailing the subject's medical history as far as it is known.
- Medical practitioners conducting such examinations should warn the subject that diving is a potentially lethal activity if undertaken by a person with certain medical conditions, and that absolute honesty in providing background medical history is called for.
- If there is any doubt about the subject's health, the medical practitioner should arrange such follow-up tests as chest X-rays, hypertonic saline tests, or whatever else may be indicated, before passing the subject as fit to dive. Any doubt should be resolved against passing the subject as fit, until such follow-up tests demonstrate fitness to dive.
- The recreational diving industry should conduct an awareness campaign among its member organisations and the diving public 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 a diver has both personally and to his or her diving colleagues to ensure that he or she is fit to dive.
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