Recurring concern

Failure to reliably recognise and control immersion pulmonary oedema risks in diving

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First reported 5 Jan 2022•Latest report 30 Apr 2026

Definition

What this concern includes

Includes failures of controls specifically dedicated to immersion pulmonary oedema in diving, including diver and medical-professional awareness, training, recognition of symptoms, risk advice during HSE medicals and escalation or referral arrangements.

Not included

  • Excludes generic diving hazards, diving fitness certification and technical-diving medical-compliance failures where immersion pulmonary oedema is not the material concern.
  • Excludes generic medical training or awareness deficiencies unrelated to recognising or managing immersion pulmonary oedema in divers.
  • Excludes cold-water immersion, drowning and immersion-related hazards that do not specifically concern immersion pulmonary oedema.
  • Excludes clinical treatment failures after immersion pulmonary oedema has been reliably recognised and appropriately escalated.
Reports
3

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2022–2026

First to latest report issue date

Stated actions
10

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

British Diving Safety Group2
Decathlon UK1
General Medical Council1
Health and Safety Executive1
National Trading Standards1
N.D.A.C. Limited1
St Richard's Hospital1
The Royal Society For The Prevention Of Accidents1
University Hospitals Sussex NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Berkshire

    AI-generated summary

    Kevin Lapwood · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kevin Lapwood, aged 63, was acting as a volunteer safety diver at Wraysbury Dive Centre on 12 February 2022 after failing an HSE medical in October 2021. He got into difficulty in very cold water and died at Wexham Park Hospital the next day; the recorded cause of death was immersion pulmonary oedema, hypertension and coronary artery disease. Concerns included medical requirements and awareness for volunteer divers, awareness of immersion pulmonary oedema risks, the guidance on shore support, and potential ambiguity in HSE legislation and guidance concerning volunteers.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of requirement for HSE medical doctors to confirm advice about immersion pulmonary oedema risks

    Wider context from the report

    “3. I am concerned that there is currently no requirement for doctors conducting HSE medicals to confirm that they have advised patients who fail the HSE medical, for reasons similar to those in Kevin’s case, of the risks of IPO. ”

    Source location

    Kevin Lapwood · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient awareness of immersion pulmonary oedema risks for divers with high blood pressure

    Wider context from the report

    “2. I am concerned about the level of training and awareness around the risks of immersion pulmonary oedema(“IPO”) for divers with high blood pressure. Whilst the more common risks of hypertension will be better understood (such as heart attack and stroke), awareness of IPO appears to be less well understood. ”

    Source location

    Kevin Lapwood · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Remind approved medical examiners of the importance of explaining diving implications of medical conditions, particularly when divers are found unfit for work.

    Verbatim wording from the response

    “Through our ongoing engagement with the AMEDs we will remind them of the importance of explaining the implications of medical conditions for diving, particularly where a person is found unfit to dive at work.”

    Source location

    Response from Health and Safety Executive
    Page 3 · response
    Published 25 June 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue promoting immersion pulmonary oedema risks through incident reports, publications, online channels, conferences, guidance, training, seminars and collaboration with water-safety organisations.

    Verbatim wording from the response

    “Since that time BSAC has increasingly promoted greater awareness of the condition through all possible avenues including but not limited to:”

    Source location

    Response from British Diving Safety Group
    Page 12 · response
    Published 25 June 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Integrate immersion pulmonary oedema guidance into the remaining Advanced Diver training programme as it is revised.

    Verbatim wording from the response

    “• Producing guidance for both Divers and Instructors on the risks, awareness, prevention and resolution of IPO.”

    Source location

    Response from British Diving Safety Group
    Page 12 · response
    Published 25 June 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Publish a further immersion pulmonary oedema article and deliver a dedicated recorded webinar for professional members.

    Verbatim wording from the response

    “SAA | Incorporates the identification and treatment of IPO into initial and second-level diver training, as well as specialized Oxygen Administration and Emergency Diver First Aid courses. | Regularly features IPO awareness pieces in newsletters sent directly to all members. PADI | Requires professionals to read provided articles regarding IPO. | Published multiple specific articles for professional members; planning another publication later this year alongside a dedicated July 2026 webinar to be archived as a permanent resource. SSI | Has added IPO/IPE information to its Science of Diving program (a prerequisite for professional membership) and its XR (Extended Range) programs. | Covering IPO in the upcoming rewrites of Open Water and Diver Stress and Rescue course materials.”

    Source location

    Response from British Diving Safety Group
    Page 4 · response
    Published 25 June 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Specific medical guidance for divers with high blood pressure should be provided by appropriately qualified medical professionals.

    Verbatim wording from the response

    “ScotSAC IPO education materials are included in our core diver training which provides an overview on the condition, symptoms and treatment from an emergency perspective. Specific medical guidance/information for any members with high blood pressure would only be provided by someone with the relevant medical qualification. All diving ScotSAC members require an annual medical certificate – the validity of this is based on the information declared by members.”

    Source location

    Response from British Diving Safety Group
    Page 14 · response
    Published 25 June 2026

    Open published response
  2. Surrey

    AI-generated summary

    Angela Jean Kearn · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Angela Jean Kearn, aged 63, collapsed and died while snorkelling in Egypt on 13 January 2020. The inquest identified immersion pulmonary oedema as the cause of death, with hypertension, hormone replacement therapy and use of a full-face snorkel mask each contributing more than minimally. Concerns included limited medical awareness of immersion pulmonary oedema and insufficiently publicised safety warnings about using full-face snorkel masks with cardiovascular or respiratory conditions.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of medical-profession awareness and training on Immersion Pulmonary Oedema

    Wider context from the report

    “Awareness of Immersion Pulmonary Oedema in the medical profession: i.) Concerns were raised by the medical witnesses that there is very little awareness of Immersion Pulmonary Oedema in the medical profession and that it is not addressed in medical training, as a consequence, it can be missed by those treating the condition and is often mistaken for drowning. ”

    Source location

    Angela Jean Kearn · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing medical education and training equip UK doctors to assess and manage rare acute conditions, including Immersion Pulmonary Oedema.

    Verbatim wording from the response

    “Through our standards and quality assurance of medical education and training we ensure that doctors in the UK are equipped with professional behaviours, knowledge, and skills to competently assess complex and uncertain acute and emergency situations. In addition, through professional clinical reasoning doctors are able to consider relevant differential diagnoses and manage acute medical emergencies including identifying people at high risk due to underlying comorbidities (such as Angela’s age and her history with hypertension).”

    Source location

    Response from General Medical Council
    Page 1 · response
    Published 31 March 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    No further specific education or training intervention is required because Immersion Pulmonary Oedema is rare and its presentation and immediate management resemble other emergencies.

    Verbatim wording from the response

    “Whilst it is not the role of the GMC to comment on specific clinical practice, Immersion Pulmonary Oedema is a rare condition and its emergency presentation may be similar to other medical emergencies. Its immediate management will also be similar and therefore we feel at this stage no further specific education and training intervention would be required. Institutions such as the Medical Royal Colleges may be able to provide you with information related to the details for a process to identify and develop areas where learning is needed and can be shared in postgraduate training across the relevant specialties and subspecialties.”

    Source location

    Response from General Medical Council
    Page 1 · response
    Published 31 March 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The level of training and medical education in Egypt is outside the respondent's jurisdiction, so it cannot comment on it.

    Verbatim wording from the response

    “I note that this case happened in Egypt. We are not able to comment on the level of training or the medical education system in Egypt as that country is outside our jurisdiction.”

    Source location

    Response from General Medical Council
    Page 2 · response
    Published 31 March 2023

    Open published response
  3. Gloucestershire

    AI-generated summary

    Richard Paul Victor Sanders · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Richard Sanders, an experienced diver aged 52, became unresponsive during a dive to 45 metres on 11 April 2019 and was pronounced deceased at the scene. The concerns included awareness of immersion pulmonary oedema risks, the need for fitness-to-dive medical certification, and methods for removing divers from the water.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of awareness of immersion pulmonary oedema risks among people participating in diving

    Wider context from the report

    “1. Whether there is sufficient awareness of the risks & affects of immersion pulmonary oedema by those engaged &/ or participating in the activity of diving. ”

    Source location

    Richard Paul Victor Sanders · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide IPO information to diving organisations and divers through the website, magazines and other publications.

    Verbatim wording from the response

    “• We also provide information directly to diving organisations and articles are published on the UKDMC website and in magazines for divers, including several in the last year.”

    Source location

    2022-0003-Response-from-St-Richards-Hospital_Published-1
    Page 1 · response
    Published 10 January 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide IPO lectures for amateur divers and make recorded lectures freely accessible online.

    Verbatim wording from the response

    “• We have provided lectures at conferences for amateur divers and some of those were recorded and can be accessed free of charge on the internet (some are on YouTube)”

    Source location

    2022-0003-Response-from-St-Richards-Hospital_Published-1
    Page 1 · response
    Published 10 January 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Work with the British Diving Safety Group and its subcommittee to increase awareness of IPO.

    Verbatim wording from the response

    “• We work with the British Diving Safety Group and its sub-committee that has the specific purpose of increasing awareness of IPO”

    Source location

    2022-0003-Response-from-St-Richards-Hospital_Published-1
    Page 1 · response
    Published 10 January 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Disseminate immersion pulmonary oedema risk information through conferences, incident reports, publications, websites, social media, webinars and water-safety engagement.

    Verbatim wording from the response

    “Actions taken to increase the awareness of IPO: There are too many individual items to list here so the individual responses from members can be made available, but in more general terms activities include but are not limited to:”

    Source location

    2022-0003-Response-from-British-Diving-Safety-Group_Published
    Page 4 · response
    Published 10 January 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Produce and distribute guidance and refresher materials for divers and instructors addressing immersion pulmonary oedema.

    Verbatim wording from the response

    “• Guidance materials produced by the BDSG members targeting divers and instructors.”

    Source location

    2022-0003-Response-from-British-Diving-Safety-Group_Published
    Page 5 · response
    Published 10 January 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Amend training materials and training programmes to teach immersion pulmonary oedema causes, presentation and distinguishing features.

    Verbatim wording from the response

    “• All training agencies have either amended or appended sections of their training materials to focus on both the causes and presentation of the condition, focussing on the ‘gas hungr[y] at depth’ to differentiate IPO from other forms of ascent related conditions.”

    Source location

    2022-0003-Response-from-British-Diving-Safety-Group_Published
    Page 5 · response
    Published 10 January 2022

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Responsibility for current diving-operation safety arrangements lies with DTSL, the new operator, which should be contacted for further information.

    Verbatim wording from the response

    “Until 23 December 2021, the Diving Centre was operated by N.D.A.C. Limited (NDAC) at Dayhouse Quarry (also known as Tidenham Quarry). However, in connection with the sale of Dayhouse Quarry to a third party, NDAC’s rights to operate the Diving Centre at the quarry were terminated as from 23 December 2021.”

    Source location

    2022-0003-Response-from-National-Diving-Activity-Centre_Published-1
    Page 1 · response
    Published 10 January 2022

    Open published response
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Data last updated 7 September 2026