Coroner's Finding: WALKER Robert Anthony

Contributing factors

• Viral myocarditis with cardiomegaly
• Pulmonary oedema due to cardiac insufficiency
• Tight wetsuit causing peripheral vasoconstriction and increased cardiac load
• Obesity and poor physical fitness
• Rapid air consumption due to breathlessness and hyperventilation
• Rapid uncontrolled ascent from depth
• Breakdown of buddy system safety procedures
• Nitrogen narcosis at 37 metres depth
• Ignoring medical advice not to dive
• Failure of diving medical examination to detect cardiac pathology

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 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
4. 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
5. 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
6. 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