Coroner's Finding: Chua, Ardebby Oh

Contributing factors

• no prior snorkelling experience
• inadequate pre-tour swimming ability assessment
• perfunctory safety briefing not tailored to inexperienced swimmers
• inadequate snorkelling demonstration on water entry
• pool noodle flotation device separated from deceased
• no buoyancy vests offered to weak swimmers
• water aspiration triggering laryngospasm
• delayed retrieval from water (18-30 minutes)
• ineffective CPR on unstable surface (muster rock)
• no practised in-water rescue procedure
• absence of supplemental oxygen on vessel
• no surfboard/backboard available for emergency retrieval

Coroner's recommendations

1. That the carriage of oxygen should be mandatory for persons operating commercial snorkelling tours
2. That the carriage of an Automated External Defibrillator should be mandatory for persons operating commercial snorkelling tours
3. That SafeWork SA conduct an audit of snorkelling tours in South Australia and report to the Coroners Court on its findings
4. That SafeWork SA advise the Coroner of the extent to which operators within South Australia are compliant with the SafeWork SA Snorkel Safety Guidelines and whether SafeWork SA are of the view that the current legislation allows them to enforce any incidence of non-compliance
5. That persons operating commercial snorkelling tours consider the purchase and placement of defibrillators within their workplaces where patrons are undertaking snorkelling activities
6. That legislation be introduced requiring all businesses conducting snorkelling activities to carry an emergency oxygen unit as part of their first aid supplies and that operators ensure that there is always a member of staff available who is appropriately trained to administer oxygen
7. That legislation be introduced requiring all businesses conducting snorkelling activities to carry an Automated External Defibrillator