Finding into death of John Robert Gregg
Deceased
John Robert Gregg
Demographics
52y, male
Date of death
2021-03-02
Finding date
2024-02-19
Cause of death
Hypoxic ischaemic encephalopathy and multi-organ failure due to coronary artery atherosclerosis in the setting of a scuba dive
AI-generated summary
John Gregg, 52, died from hypoxic ischaemic encephalopathy and multi-organ failure following cardiac arrest during a recreational scuba dive. Autopsy revealed severe coronary artery atherosclerosis and borderline cardiomegaly, predisposing him to cardiac arrhythmia during physical exertion. Critical clinical lessons: (1) John failed to disclose significant medical history on pre-dive medical questionnaire, including prescription medications, prior pneumonia requiring ICU admission, and recurrent back problems—his GP stated he would not have endorsed diving without formal dive medical clearance; (2) John's equipment had a faulty pressure gauge with 20-bar discrepancy, meaning actual cylinder pressure was critically low when he began struggling; (3) inadequate resuscitation equipment on the dive charter vessel—no AED or bag-valve-mask available for 100% oxygen delivery; (4) John ran out of air at depth and could not maintain buoyancy. Earlier medical screening, formal dive medical assessment, equipment maintenance verification, and onboard resuscitation equipment might have prevented or better managed this outcome.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Severe coronary artery atherosclerosis with severe narrowing of major coronary artery
- Borderline cardiomegaly
- Failure to disclose medical history on pre-dive medical questionnaire
- Faulty pressure gauge on diving equipment with 20-bar discrepancy
- Heavy resistance to gas flow in primary regulator
- Inadequate air reserve in cylinder at depth
- Failure to return to surface with appropriate air safety buffer
- Inadequate resuscitation equipment on charter vessel
- Possible cardiac arrhythmia triggered by exertion during diving
- Possible air starvation contributing to incapacitation
Coroner's recommendations
- Standards Australia and relevant stakeholders should amend Australian Standards to require recreational dive providers to: (a) ensure divers understand medical conditions elevating diving risks and importance of accurate medical screening; (b) require all divers over 45 years of age to complete and produce a current dive medical for all dives over 18 metres; (c) require all divers to demonstrate understanding and proficiency in emergency drills for dives over 18 metres including weight removal and buddy breathing.
- Standards Australia and relevant stakeholders should amend Australian Standards to require recreational dive charter operators to carry: (a) adequate medical equipment including oxygen resuscitation equipment capable of providing 100% inspired oxygen to spontaneously breathing patients and oxygen-enriched artificial ventilation for non-breathing patients; (b) an Automated External Defibrillator (AED) with appropriate training provided to staff.
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