Coronial
TAScommunity

Coroner's Finding: AW

Deceased

AW

Demographics

57y, male

Date of death

2021-12-24

Finding date

2024-04-10

Cause of death

cerebral arterial gas embolism (CAGE)

AI-generated summary

A 57-year-old experienced commercial diver died from cerebral arterial gas embolism (CAGE) while recreational hookah diving near St Helens Island, Tasmania on 24 December 2021. His diving equipment had multiple critical safety defects: the compressor delivered only 35% of its rated airflow, lacked adequate carbon monoxide filtration, had a non-functioning throttle governor, an excessively long hose, and a non-ditchable weighted jacket. After experiencing breathing difficulties at 21 metres depth, he attempted diving at shallower depth but likely made a rapid uncontrolled ascent causing gas embolism. Probable carbon monoxide exposure may have caused confusion contributing to the emergency. The death was entirely preventable through proper equipment maintenance, regular inspection protocols, and adherence to safety practices including accessory air supply, buoyancy apparatus, and easily-releasable weights.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

diving medicinehyperbaric medicineemergency medicineforensic medicine

Error types

proceduralsystem

Clinical conditions

cerebral arterial gas embolismcarbon monoxide poisoningdecompression injurybarotrauma

Procedures

hookah divingrecreational diving with compressor system

Contributing factors

  • inadequate equipment maintenance
  • compressor delivering only 180 litres per minute instead of 509.8 litres per minute
  • insufficient air filtration and lack of carbon monoxide removal
  • inappropriate snorkel and exhaust arrangement drawing contaminated air
  • non-functional throttle governing mechanism
  • poorly adjusted compressor relief valve
  • excessively long diving hose reducing flow and pressure
  • non-ditchable weighted jacket
  • worn and leaking hose fittings
  • likely rapid ascent from depth
  • probable carbon monoxide poisoning causing confusion
  • absence of accessory air supply
  • absence of buoyancy apparatus
  • lack of regulatory oversight of recreational hookah diving equipment

Coroner's recommendations

  1. Hookah owners must ensure their apparatus is a life support system that is fit for purpose, well maintained, and produces adequate supply of good quality breathing air
  2. Hookah divers should, where possible, carry an accessory air supply and a buoyancy apparatus for use in an emergency
  3. Hookah divers should ensure they can easily release their weight belt in an emergency
  4. Agencies and bodies involved in this area should continue to promote hookah diving safety educational video and promulgate safety messages for hookah divers generally
  5. Consider introducing regulatory oversight of recreational hookah diving and an inspection system to assess apparatus safety and maintenance schedules
Full text
Official source Archived copy

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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —