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Diving accidents result from a variety of causes including human error, inadequate health and fitness, environmental hazards and equipment problems. They usually involve a cascade of events resulting in the diver being injured or deceased. The accuracy and usefulness of a diving accident investigation relies on well-targeted interviews, good field investigation, evidence collection and preservation, and appropriate equipment assessment. In the event of a fatality, a thorough and targeted autopsy is indicated. Investigators should have the appropriate knowledge, training, skills and support systems to perform the required tasks. Relevant investigations include the victim's medical and diving history, the dive circumstances and likely accident scenario, management of the accident including rescue and first aid, equipment inspection and testing and a thorough postmortem examination conducted by a forensic pathologist with an awareness of the special requirements of a diving autopsy and the knowledge to correctly interpret the findings. A chain of events analysis can determine the likely accident scenario, identify shortcomings and inform countermeasures.

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Introduction: Tasmania is a small island state off the southern edge of Australia where a comparatively high proportion of the 558,000 population partake in recreational or occupational diving. While diving is a relatively safe sport and occupation, Tasmania has a significantly higher diving death rate per head of population than other States in Australia (four times the national diving mortality rate). Methods: Three compressed gas diving deaths occurred in seven months between 2021-2022 prompting a review of the statewide approach for the immediate response of personnel to diving-related deaths. The review engaged first responders including the Police Marine and Rescue Service, hospital-based departments including the Department of Hyperbaric and Diving Medicine, and the mortuary and coroner's office. Results: An aide-mémoire for all craft groups, digitalised checklists for first responders (irrespective of diving knowledge), and a single-paged algorithm to highlight inter-agency communication pathways in the event of a diving death were designed to enhance current practices and collaboration. Conclusions: If used, these aids for managing diving related deaths should ensure that time-critical information is appropriately captured and stored to optimise information provided for the coronial investigation.

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The present study aims to investigate the demographics and characteristics of scuba diving fatalities in the Philippines which can help in the identification of local trends and ultimately in the development of appropriate preventive measures. Data on scuba diving-related fatalities in the Philippines from 2008 to 2022 were manually retrieved from online news media sources. Information on age, sex, nationality, certification, purpose, and causative factors, whenever possible were collected and analysed. A total of 39 fatalities were identified having a median age of 43.5 (range 20-80). Majority of victims were males (n = 30), and of foreign ethnicity (n = 26). Asphyxia was identified as the possible disabling injury in almost half of the cases (n = 17). The causes of death based on autopsies were determined only for few cases which included drowning (n = 2), heart attack (n = 1), and traumatic injuries from a dynamite blast (n = 1). Potential vulnerable groups were identified to be the ageing population and foreign tourist divers. In the absence of an existing database, this preliminary report provides the best available evidence at this time concerning scuba diving fatalities in the Philippines.

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Introduction: Chest compression often cannot be administered using conventional techniques in a diving bell. Multiple alternative techniques are taught, including head-to-chest and both prone and seated knee-to-chest compressions, but there are no supporting efficacy data. This study evaluated the efficacy, safety and sustainability of these techniques. Methods: Chest compressions were delivered by a team of expert cardiopulmonary resuscitation (CPR) providers. The primary outcome was proportion of chest compressions delivered to target depth compared to conventional CPR. Techniques found to be safe and potentially effective by the study team were further trialled by 20 emergency department staff members. Results: Expert providers delivered a median of 98% (interquartile range [IQR] 1.5%) of chest compressions to the target depth using conventional CPR. Only 32% (IQR 60.8%) of head-to-chest compressions were delivered to depth; evaluation of the technique was abandoned due to adverse effects. No study team member could register sustained compression outputs using prone knee-to-chest compressions. Seated knee-to-chest were delivered to depth 12% (IQR 49%) of the time; some compression providers delivered > 90% of compressions to depth. Conclusions: Head-to-chest compressions have limited efficacy and cause harm to providers; they should not be taught or used. Prone knee-to-chest compressions are ineffective. Seated knee-to-chest compressions have poor overall efficacy but some providers deliver them well. Further research is required to establish whether this technique is feasible, effective and sustainable in a diving bell setting, and whether it can be taught and improved with practise.

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Introduction: Provision of manual chest compressions in a diving bell using a conventional technique is often impossible, and alternative techniques are poorly evidenced in terms of efficacy and sustainability. The first mechanical cardiopulmonary resuscitation (CPR) device suitable for use in this environment, the NUI Compact Chest Compression Device (NCCD), has recently been designed and manufactured. This study assessed both the efficacy of the device in delivering chest compressions to both prone and seated manikins, and the ability of novice users to apply and operate it. Methods: Compression efficacy was assessed using a Resusi Anne QCPR intelligent manikin, and the primary outcome was the proportion of compressions delivered to target depth (50-60 mm). The gold standard was that achieved by expert CPR providers delivering manual CPR; the LUCAS 3 mCPR device was a further comparator. Results: The NCCD delivered 100% of compressions to target depth compared to 98% for the gold standard (interquartile range 1.5%) and 98% for the LUCAS 3 when applied to both supine and seated manikins. The NCCD sometimes became dislodged and had to be reapplied when used with a seated manikin. Conclusions: The NCCD can deliver chest compressions at target rate and depth to both supine and seated manikins with efficacy equivalent to manual CPR and the LUCAS 3. It can become dislodged when applied to a seated manikin; its design has now been altered to prevent this. New users can be trained in use of the NCCD quickly, but practise is required to ensure effective use.

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Introduction: This study investigated snorkelling and breath-hold diving deaths in Australia from 2014-2018 and compared these to those from 2001-2013 to identify ongoing problems and assess the effectiveness of countermeasures. Methods: Media reports and the National Coronial Information System were searched to identify snorkelling/breath-hold diving deaths for 2014-2018, inclusive. Data were extracted from witness and police reports, medical histories, and autopsies. An Excel® database was created and a chain of events analysis conducted. Comparisons were made with the earlier report. Results: Ninety-one fatalities (78 males, 13 females, median age 48 years [range 16-80]) were identified with one third likely doing some breath-hold diving. Fifty-two of 77 with known body mass index were overweight or obese. Approximately two thirds were inexperienced snorkellers and 64 were alone. Fifty-one were tourists. Planning shortcomings, such as solo diving and diving in adverse conditions, as well as pre-existing health conditions and inexperience predisposed to many incidents. Primary drowning was the likely disabling condition in 39% of cases with drowning recorded as the cause of death (COD) in two thirds. Cardiac events were the likely disabling conditions in 31% although recorded as the COD in 21% of cases. Conclusions: Increasing age, obesity and associated cardiac disease have become increasingly prevalent in snorkelling deaths and there is a need for improved health surveillance and risk management. Closer supervision of inexperienced snorkellers is indicated. Apnoeic hypoxia from extended breath-holding and poor supervision remain a problem. The increased risk of harvesting seafood in areas frequented by large marine predators needs to be appreciated and managed appropriately.

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INTRODUCTION: This study aimed to investigate compressed gas diving deaths in Australia from 2014-2018 and make comparison to those from 2001-2013 to identify ongoing problems and assess countermeasures. METHODS: Media reports and the National Coronial Information System were searched to identify scuba diving deaths for 2014-2018, inclusive. Data were extracted from the witness and police reports, medical histories, and autopsies. An Excel® database was created and a chain of events analysis conducted. Comparisons were made with the earlier report. RESULTS: Forty-two fatalities were identified, 38 using scuba and four using surface-supplied breathing apparatus involving 30 males and 12 females. The mean age of victims was 49.7 years, six years higher than the previous cohort. Fifty-four percent were obese. Six victims were unqualified, three were under instruction and at least 28 were experienced divers, significantly more than in the previous cohort. Health-related predisposing factors, predominantly obesity and cardiac-related, were identified as likely contributory to 26 incidents, and planning shortcomings to at least 22 deaths. One-third of the disabling conditions were primary drowning and one-quarter were cardiac. Three divers died subsequent to carbon monoxide poisoning and three likely from immersion pulmonary oedema. CONCLUSIONS: Advancing age, obesity and the associated cardiac disease have become increasingly prevalent in diving fatalities and the need for appropriate assessment of fitness to dive is evident.

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INTRODUCTION: This study aimed to develop a standard process and checklist for technical investigation of hookah diving equipment and apply it to Tasmanian hookah fatality investigations from the last 25 years. METHODS: A literature search was undertaken to identify technical reports and equipment investigations associated with diving accidents. The information was assimilated to create a process and checklist for specifically assessing the hookah apparatus. The checklist was then applied in a gap analysis of Tasmanian hookah diving fatality technical reports from 1995 to 2019. RESULTS: As no papers specifically describing technical evaluation of hookah equipment were identified, references evaluating scuba equipment were used to create a hookah technical assessment process incorporating unique features of the hookah. Features included: owner responsibility for air quality; maintenance, function; exhaust proximity to air intake; reservoir volume; output non-return valves; line pressure; sufficiency of supply; entanglement; hose severance risk; gas supply failure and hosing attachment to the diver. Seven hookah diving deaths occurred in Tasmania (1995-2019) of which three had documented technical assessment. Gap analysis identified inconsistent structure between reports with variability in the case descriptors. Missing technical data included: overview of the hookah systems; accessories; weights; how the apparatus was worn by the diver; compressor suitability; assessment of hookah function; breathing gas output and exhaust position relative to air intake. CONCLUSIONS: The study demonstrated a need to standardise technical reporting of hookah equipment after diving accidents. The checklist generated may serve as a resource for future hookah assessments and inform strategies for preventing future hookah accidents.

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Introduction: In fatal accidents during scuba diving, it is necessary to differentiate a death from primary drowning from a secondary drowning death that is primarily due to other etiopathogenetic factors. The inhalation of water can only be the end point of a series of events capable of causing the diver's exitus. This study aims to demonstrate that even low-risk heart disease in daily life become potentially fatal during scuba diving. Methods: In this case series, we describe all cases of deaths in the course of diving that came to the observation of the Forensic Institute of the University Bari over 20 years (2000-2020). A judicial autopsy was performed on all subjects, with ancillary execution of histological and toxicological investigations. Results: The results of the medicolegal investigations carried out in the complex identified heart failure with acute myocardial infarction as the cause of death in four cases characterized by severe myocardiocoronarosclerosis, a primary drowning in a subject without previous pathological substrate in one case, and a terminal atrial fibrillation induced by acute dynamic heart failure due to functional overload of the right ventricle in one case. Conclusion: Our study demonstrates that lethal events during diving are often related to the presence of unrecognized or subclinical cardiovascular diseases. Such deaths could be prevented and avoided if a greater regulatory sensitivity to preventing and controlling diving was encouraged, considering both the inherent risks of this activity and the possible unrecognized or underestimated pathologies.

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Aim: Reports of fatal incidents in recreational scuba divers from carbon monoxide (CO) poisoning are rare. This study aimed to identify scuba fatalities in the Asia-Pacific region caused by breathing-gas contamination to better understand the likely sources of contamination and reduce such preventable deaths. Methods: A hand search of Project Stickybeak reports, subsequent Australian fatality series reports, and of published New Zealand diving fatality reports and associated data was conducted, as well as key word searches of the National Coronial Information System for scuba fatalities in Australia and New Zealand. Cases identified were matched with the Australasian Diving Safety Foundation diving fatality database. Available reports were examined. Results: Four scuba deaths resulting from CO poisoning were identified from 645 scuba fatalities, including one report from each of Australia, New Zealand, Singapore, and the Maldives. A near-fatal incident was also identified in Indonesia. Two of the fatal incidents and the near-fatal incident involved internal combustion engine exhaust gases from the compressor system or elsewhere entering the air intake. Two deaths likely resulted from combustion within compressor systems. Conclusions: Scuba fatalities from CO poisoning are uncommon, albeit likely under-reported. Sources of CO include exhaust gases entering the compressor and CO production by pyrolysis or gasification within the compressor or its filter system. Preventive measures include proper installation (including positioning of the air intake relative to combustion exhaust), appropriate maintenance, fitting of pressure-maintaining valves and avoidance of overheating. Formal training of compressor operators, improved diver education, mandatory requirements for installation compliance assessments, safety inspections, and the use of carbon monoxide alarms are recommended.

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INTRODUCTION: This study examined all known diving-related fatalities in Queensland, Australia, from 2000 to 2019 to determine likely causes and potential countermeasures. METHODS: Data were extracted from the Australasian Diving Safety Foundation fatality database, including previously published reports. The National Coronial Information System was searched to identify diving-related deaths in Queensland for 2014-2019 and data were extracted, analysed, and combined with previously published data covering the period 2000-2013. Descriptive statistics and parametric and non-parametric tests were used to analyse these data. RESULTS: There were 166 snorkelling and 41 scuba victims identified with median ages of 59 and 49 years respectively, and 83% of snorkel and 64% of scuba victims were males. One quarter of snorkel and 40% of scuba victims were obese. Two-thirds of the snorkellers and three quarters of scuba divers were overseas tourists. Contributory predisposing health conditions were identified in 61% of snorkel and 50% of scuba victims. Nine scuba victims died on their first dive. CONCLUSIONS: The increase in snorkelling deaths likely reflects increased participation, higher age, and poorer health. The main disabling condition in both cohorts was cardiac-related. Pre-existing health conditions, poor skills, inexperience, poor planning, supervision shortcomings and lack of effective buddy systems featured in both cohorts, and apnoeic hypoxia in breath-hold divers. Suggested countermeasures include improved education on the importance of health and fitness for safe diving and snorkelling, increased emphasis on an honest and accurate pre-activity health declaration and subsequent implementation of appropriate risk mitigation strategies, improved supervision, better buddy pairing, and on-going education on the hazards of extended apnoea.

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Nowhere is redundancy more indispensable than extended range cave diving. Training and practice in this discipline ensure divers are equipped with backup regulators, gauges, lights, and adequate breathing gas for a safe exit, emergencies, and decompression. Depending on penetration distances and depth, open circuit cave diving may require carrying more gas cylinders than can be logistically managed by the diver themselves while maintaining safe gas supply margins. Consequently, divers are forced to either stage cylinders in the cave prior to the dive or rely on resupply from support divers. Both scenarios have significant drawbacks. Due to the improved efficiency of breathing gas utilisation and other advantages, closed circuit rebreathers (CCR) have enabled extended range cave diving. With increasing depths, penetration distances, and bottom times, these divers must also plan for an increasing amount of open circuit bail-out gas in the event of CCR failure. Staged cylinders have traditionally been utilised, but this strategy has limitations due to the advanced dives needed to place them and equipment degradation due to prolonged water immersion, which can often result in cylinder and regulator corrosion with consequent leakage of contents over time. Consequently, a growing number of CCR divers are foregoing open-circuit bailout altogether by carrying an additional CCR system for bailout. Although these bailout rebreathers may facilitate further exploration and have certain advantages, the risks of diving with two complex machines remain to be clearly defined.

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INTRODUCTION: New Zealand (NZ) diving-related fatalities have been reported since the 1960s. The aim is to identify contributing risk factors, including medical, and to inform appropriate preventative strategies. METHODS: NZ scuba diving fatalities from 2007 to 2016 were searched from multiple sources - the National Coronial Information System (NCIS); the NZ Chief Coroner's office; Water Safety NZ Drownbase™ and the NZ Police National Dive Squad records. For inclusion, a victim must have been wearing a scuba set (which may include a rebreather). A key word search of the NCIS was made and the results matched to the other databases. An Excel® database was created and a chain of events analysis (CEA) conducted. RESULTS: Forty-eight scuba diving fatalities were identified, 40 men and eight women, average age 47 years (range 17-68), 20 of Maori ethnicity. Thirty-five were classified as overweight (14) or obese (21). Pre-existing medical risk factors were identified, either pre dive or at autopsy, in 37 divers, the commonest being ischaemic heart disease (IHD, 20), left ventricular hypertrophy (LVH, 18) and hypertension (seven). IHD, LVH and obesity were variously associated with each other. The likely commonest disabling conditions, identified in 32 cases, were asphyxia (15), cardiac (nine) and pulmonary barotrauma/cerebral arterial gas embolism (five). Multiple environmental and diving practice breaches and poor planning were identified in the CEA, similar to those seen in other studies. Thirty-eight divers had not released their weight belt. Information on resuscitation was limited. CONCLUSIONS: Obesity and cardiovascular disease were common and Maori appear to be over-represented, both as previously reported.

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INTRODUCTION: The aim of this study was to describe the nature of regular medications taken by active comorbid scuba divers (having a declared medical comorbidity) and scuba divers and snorkellers who died following a diving incident. METHODS: We undertook a retrospective, observational study from July to October, 2020. Data on 268 active comorbid divers were obtained through a 2013 survey of Divers Alert Network Asia-Pacific members. Data on 126 deceased scuba divers and 175 deceased snorkellers were obtained predominantly from 2001-2013 reports to Australian State Coronial Services. RESULTS: The active comorbid divers were significantly older, less likely to be male, and more likely to be taking one or more medications than the two deceased subject groups (P < 0.001). Cardiovascular, endocrine and psychotropic medications accounted for 53.4%, 9.9% and 6.4% of all medications taken, respectively. Almost one tenth of the deceased divers took at least one psychotropic medication, a proportion significantly greater than the other groups (P = 0.01). CONCLUSIONS: Medication use among active comorbid divers is common which likely reflects their declared medical condition. Nevertheless, they appear to be diving relatively safely, often with conditions once thought to be absolute contradictions to scuba diving. The deceased divers took significantly more psychotropic medications. It is possible that their underlying psychological/psychiatric conditions rendered them more at risk of a diving incident. Increased vigilance for psychological conditions may need to be considered during diving medical examinations.

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INTRODUCTION: The aim of this study was to re-examine the mortality rate among participants in the Professional Association of Diving Instructors' (PADI)'s Discover Scuba Diving (DSD) programme. METHODS: Fatalities reported to PADI as having occurred during DSD scuba dives were counted for each year between 1992 and 2019. DSD participant registrations were also counted for each year. The data were conveniently divided into two equal 14-year periods, 1992-2005 ('early') and 2006-2019 ('late'). To smooth out the year-to-year variation in raw rates, Monte Carlo simulations were performed on the mean rate per 100,000 participants per year during each period. RESULTS: There were a total of 7,118,731 DSD participant registrations and 79 fatalities during the study period. The estimated overall mean mortality rate in the early period was 2.55 per 100,000 DSD registrations whereas the estimated rate of 0.87 per 100,000 DSD registrations was significantly lower in the late period (P < 0.0001). CONCLUSIONS: PADI's contemporary Discover Scuba Diving introductory scuba experiences, at 0.87 fatalities per 100,000 participants, have a calculated mortality rate that is less than half that calculated for 1992-2008. The late period's rate improvement appears due either to significant under-registration in the early period, or to significant safety-performance improvement in the late period or, more likely, some combination of the two.

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INTRODUCTION: This study identified characteristics and diving practices of victims of fatal surface supplied breathing apparatus (SSBA) incidents in Australia from 1965-2019 to determine underlying factors and risks associated with these activities, better educate the diving community and prevent such deaths. METHODS: A hand search was made of 'Project Stickybeak' reports from 1965-2000 and SSBA fatality data were compared to the Australasian Diving Safety Foundation fatality database. The National Coronial Information System was searched to identify SSBA diving deaths for 2001-2019. Extracted data were collated and analysed using descriptive statistics and Poisson Regression. A chain of events analysis was used to determine the likely sequence of events. RESULTS: There were 84 identified SSBA-related deaths during the study period. Most victims were relatively young, healthy males (median age 33 years). At least 50% of victims were undertaking work-related diving, and 37% were recreational diving. Equipment issues, mainly compressor-related, were the main contributor, identified as a predisposing factor in 48% of incidents and as triggers in 24%. CONCLUSIONS: Preventable surface-supplied diving deaths still occur in both occupational and recreational diving, often from poor equipment maintenance and oversight. Incorrect configuration of the SSBA and lack of training remain on-going problems in recreational users. These could be addressed by improved education, and, failing this, regulatory oversight. The increase in health-related incidents in older participants may be controlled to some extent by greater medical oversight, especially in recreational and non-certified occupational divers who should be encouraged to undergo regular diving medical assessments.

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INTRODUCTION: New Zealand's (NZ) long coastline offers a diverse underwater environment with abundant opportunities for harvesting seafood and for recreation. Fatalities from snorkelling/breath-hold diving have been reported from the 1960s through to 2006. Those from 2007 to 2016 are reported here. METHODS: The National Coronial Information System, the Australasian Diving Safety Foundation diving fatality database, and the Water Safety NZ "Drownbase" were searched and additional coronial data provided by the NZ Ministry of Justice. An anonymised database was created and analysed for multiple factors. A chain of events analysis was performed for each case. RESULTS: There were 38 snorkelling or breath-hold-related deaths in NZ, 33 men and five women. Twenty-nine were breath-hold divers involved in gathering seafood, and six 'surface snorkellers', predominantly sightseeing. Two-thirds were diving alone and/or were not being observed by anyone out of the water. Twenty-eight victims were classified as overweight or obese and 19/38 were Maori. Pre-existing health factors that may have or definitely contributed to the fatality were present in 30 cases. The most common of these were cardiac (18/38). Two divers had insulin-dependent diabetes mellitus, one each epilepsy and asthma whilst cannabis and/or alcohol were possible factors in seven deaths. Five (possibly six) deaths resulted from apnoeic hypoxia. CONCLUSIONS: Overall, death from snorkelling/breath-hold diving was an uncommon event (38 in 10 years). Poor judgement was a common feature. Middle-aged Maori men with pre-existing disease feature strongly. This suggests an on-going need for appropriate water safety education within and beyond the Maori community.

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INTRODUCTION: Hydration status is considered a parameter likely to influence the risk of decompression sickness (DCS), but scientific evidence is scarce and conflicting. This experiment aimed to analyse the influence of pre-hydration on DCS occurrence in a rat model. METHODS: Intra-peritoneal injections of saline solution were administered to rats (NaCl 0.9% 0 ml (Control), 0.1 ml (Group 1), or 1 ml·100g-1 body mass (Group 2) at each of 24 h, 12 h, and 30 min prior to simulated air dives (45 min at 1,010 kPa; compression and decompression rates 101 kPa·min-1; stops 5 min at 202 kPa, 5 min at 160 kPa, 10 min at 130 kPa). Evaluation of DCS occurrence and severity was made after decompression. RESULTS: Pre-dive hydration reduced severe DCS from 47% (Control) to 29% (Group 1) and 0% (Group 2), and increased the proportion of animals without any signs of DCS from 40 (Control) to 57% (Group 1) and 93% (Group 2); Chi2 P = 0.041. CONCLUSIONS: This experiment demonstrated that pre-hydration can drastically reduce the DCS occurrence in an animal model. In the context of scuba diving, this result highlights the importance of elucidating the mechanisms linking hydration status and DCS risk.

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INTRODUCTION: This study identified pre-existing medical conditions among scuba diving fatalities in Australia from 2001 to 2013, inclusive, and assessed whether these conditions likely contributed to the deaths. METHODS: The National Coronial Information System (NCIS) was searched for scuba diving-related cases during 2001-2013, inclusive. Coronial findings, witness and police reports, medical histories, and autopsy and toxicology reports were scrutinised for pre-existing medical conditions and autopsy findings. Predisposing factors, triggers, disabling agents, disabling injuries and causes of death were analysed using a validated template. RESULTS: There were 126 scuba diving-related fatalities identified during the study period. Forty-six (37%) divers were identified as having a significant medical condition which may have contributed to their incident. The most common condition was ischaemic heart disease (IHD) which had been diagnosed in 15 of the divers. Thirty-two (25%) deaths were attributed to cardiac disabling injuries (DI) such as ischaemic heart disease and arrhythmias, although a cardiac DI was thought likely in another six. Respiratory conditions were implicated in eight (6%) deaths, at least four associated with cerebral arterial gas embolism. At least 14 (11%) divers who had contributory pre-existing medical conditions had been cleared to dive by a medical practitioner within the year prior. CONCLUSIONS: Chronic health-related factors played a major role in almost half of these deaths; primarily cardiac conditions such as IHD and cardiac arrhythmias. Although fitness-to-dive (FTD) assessments have limitations, the high incidence of cardiac-related deaths indicates a need for 'older' divers to be medically assessed for FTD.

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