Coronial
VIChospital

Finding into death of Reagan Leon Milstein

Deceased

REAGAN LEON MILSTEIN

Demographics

14y, male

Date of death

2010-07-22

Finding date

2012-10-23

Cause of death

complications of cerebral arterial gas embolism due to SCUBA incident

AI-generated summary

Reagan Milstein, a 14-year-old certified junior open water diver, died from complications of cerebral arterial gas embolism (CAGE) sustained during a recreational dive in Malaysia. He became unconscious during his second dive and was retrieved from the water, but treatment was severely compromised by multiple preventable factors: no 100% oxygen was available on the dive boat; he received inadequate oxygen therapy in hospital (less than 40% inspired oxygen); treating physicians had no experience with diving illness and did not diagnose decompression illness for 6 hours; and critically, a decompression chamber was not accessed until 32 hours post-incident. The underlying cardiac cause (PFO, ASD, or other) could not be definitively identified without autopsy. Clinical lessons include the importance of immediate high-concentration oxygen provision, rapid specialist consultation (DAN emergency hotline available 24/7), and early hyperbaric therapy for suspected diving emergencies.

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

Contributing factors

  • absence of 100% oxygen on dive boat
  • inadequate oxygen therapy with non-rebreather mask and simple face mask unable to deliver high oxygen concentrations
  • treatment by physicians with no experience in diving illness or decompression sickness
  • delayed diagnosis of decompression illness (6 hours post-dive)
  • delayed access to decompression chamber (32 hours post-dive)
  • failure to contact diving emergency hotline immediately
  • possible underlying cardiac pathology (PFO or ASD) not screened pre-dive
  • lack of preparedness for diving emergency in Malaysia

Coroner's recommendations

  1. Commonwealth Department of Foreign Affairs and Trade should partner with Divers Alert Network Asia-Pacific to develop detailed advice on the Smartraveller website to allow Australians to undertake appropriate safety assessments and preparations for recreational diving overseas
  2. Department of Foreign Affairs and Trade should notify recreational diving training and certification organisations operating in Australia of the presence of this information, encouraging divers to review Smartraveller before diving overseas
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