Coroner's Finding: AW

57y · Male·cerebral arterial gas embolism (CAGE)

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.