Finding into death of Leonie Maree Hanson
Deceased
Leonie Maree Hanson
Demographics
40y, female
Date of death
2016-06-10
Finding date
2020-05-14
Cause of death
Drowning
AI-generated summary
Leonie Hanson, an experienced diving instructor, drowned at Mornington Pier while attempting to rescue a student, Logan Saminathan, who surfaced unconscious during an open water training dive. The student likely panicked underwater in severe conditions (40 km/h winds, 2-metre waves, 12°C water), possibly after removing his mask. Hanson became exhausted attempting rescue and failed to activate standard emergency procedures (ditching weights, inflating her buoyancy device, using her regulator). Key clinical lessons: risk assessment for diving operations must account for worst-case scenarios and inexperienced divers' vulnerability to panic in cold water and adverse conditions. Emergency response plans should include specific procedures for extracting unconscious divers. Hanson's failure to implement safety procedures despite training suggests acute stress-induced inaction. The absence of a comprehensive emergency plan for the site and inadequate assessment of prevailing hazards contributed to this tragedy.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- Adverse weather conditions (40 km/h winds, 2-metre waves, 12°C water temperature)
- Inadequate risk assessment for prevailing conditions
- Absence of comprehensive emergency plan for unconscious diver recovery
- Instructor's failure to cancel or modify dive given unsuitable conditions
- Student's panic response and loss of mask underwater
- Instructor's failure to activate emergency procedures (ditching weights, inflating BCD/dry suit)
- Exhaustion from rescue attempt in severe sea conditions
- Strong surge and water movement under the pier barriers
- Potential mild hypothermia in student from cold exposure during surface interval
Coroner's recommendations
- Dive leaders and diving professionals must carefully assess site suitability under prevailing conditions, especially for highly inexperienced divers, considering worst-case scenarios and erring on the side of caution
- A comprehensive plan to remove an unconscious diver from the water should be formulated and practised for every diving site, with special equipment considered as necessary
- For sites in common use, a formal emergency plan should be devised and practised by dive professionals
- SSI diving service providers should ensure written emergency plans for each training location specifically address procedures for recovering unconscious divers from the water
- Parks Victoria should consider trialling the provision of lifebuoys at Mornington Pier and other piers along the Mornington Peninsula where dive schools frequently operate for a three-year period and assess their usefulness (informal recommendation)
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