30 Apr 2026 Kevin Lapwood · Prevention of Future Deaths report Berkshire
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Concerns raised 5 Lack of requirement for HSE medical doctors to confirm advice about immersion pulmonary oedema risks View source Insufficient awareness of immersion pulmonary oedema risks for divers with high blood pressure View source Insufficient guidance on the duties of shore support or surface cover View source Insufficient training and awareness of medical requirements for volunteer divers View source Ambiguity in legislation and guidance about applicability to volunteer divers View source See 2 more concerns
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 9
Action
Review Dive Marshal guidance to incorporate explicit eyes-on-the-water requirements.
View source
Action
Revise resources to strengthen instructors’ awareness and enforcement of Diving at Work Regulations medical requirements.
View source
Action
Rewrite shore-cover guidance defining the roles and responsibilities of shore support.
View source
Action
Form a working group to define recommended qualifications and good practices for shore cover.
View source
Action
Publish a further immersion pulmonary oedema article and deliver a dedicated recorded webinar for professional members.
View source
Action
Review Dive Management guidance to address the concern that shore support should maintain eyes on the water.
View source
Action
Integrate immersion pulmonary oedema guidance into the remaining Advanced Diver training programme as it is revised.
View source
Action
Implement a UK-specific addendum training SSI professional trainers on UK Diving at Work Regulations and Approved Code of Practice requirements.
View source
Action
Continue promoting immersion pulmonary oedema risks through incident reports, publications, online channels, conferences, guidance, training, seminars and collaboration with water-safety organisations.
View source See 6 more actions
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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.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Diving Safety Group; that does not assign responsibility.
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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Diving Safety Group; that does not assign responsibility.
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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Diving Safety Group; that does not assign responsibility.
PFD Monitor interpretation Insufficient guidance on the duties of shore support or surface cover
Wider context from the report “3. I am concerned about whether there is sufficient guidance regarding what the role of shore support /surface cover entails . Specifically, should that include having eyes on the water?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Diving Safety Group; that does not assign responsibility.
PFD Monitor interpretation Insufficient training and awareness of medical requirements for volunteer divers
Wider context from the report “1. I am concerned about the level of training and awareness nationally – specifically of the medical requirements for volunteers involved in projects like Kevin was .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Diving Safety Group; that does not assign responsibility.
PFD Monitor interpretation Ambiguity in legislation and guidance about applicability to volunteer divers
Wider context from the report “1. Clarity of the approved code of practice (‘ACOP’) entitled “Recreational diving projects – Diving at Work Regulations 1997”, published in 2014, in the following respects:
a. The title of the document – does this document adequately reflect that it also covers volunteers? Is there a risk that, on reading the initial heading of the document, it may be felt that it is not relevant to volunteers working in the capacity that Kevin did?
b. Would the reference to “associated guidance” on the title page be better with the use of a hyperlink to guidance such as the volunteer diver guidance note?
c. The definition of “diver” in the ACOP is “a person at work who dives”. The definition of “at work” is (in summary) an employee or a self-employed person. Although the guidance does go on to deal separately with those in a diving role as part of a project, there is some potential ambiguity here . For instance, it may be possible to look at the guidance on Regulation 12 which states that no “diver” shall dive in a diving project unless he has an HSE medical. If “diver” is defined as being somebody at work, then there is a risk that the regulations could be interpreted in the way it appears they were here – ie only applying to somebody who is paid.
A careful reading of the guidance should make the position clearer, but I believe there is a remaining risk of misinterpretation without very careful analysis of this document .
2. All the titles of the relevant legislation and guidance refer to diving “at work”. It is easily foreseeable that someone looking at this may assume that it is not relevant for volunteers used as part of a diving project . I appreciate that naming legislation is not within the gift of the HSE, but it may be something that could be communicated in relation to future legislation, and taken into account in HSE guidance – particularly the titles of any future guidance.
” Open source report
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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 Review Dive Marshal guidance to incorporate explicit eyes-on-the-water requirements.
Verbatim wording from the response “The SAA utilizes a Dive Marshal system to monitor divers but acknowledges their current guidance does not explicitly state the phrase "having eyes on the water." They have committed to reviewing their standards to address the Coroner's specific concern.” Source location Response from British Diving Safety Group
Open published response
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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 Revise resources to strengthen instructors’ awareness and enforcement of Diving at Work Regulations medical requirements.
Verbatim wording from the response “Considering the Coroner's report, PADI is actively revising its resources to heavily stress and enforce awareness of these specific DWR medical requirements. | Requires all Divemasters and Instructors to be examined and declared fit to dive by a physician prior to qualifying.
SAA | Warns members that any element of reward/payment triggers DWR and voids SAA insurance. Acknowledges that commercial volunteer projects are too complex for their expertise, advising contractors to seek formal legal advice. | Utilizes the UKDMC self-cert recreational screening system (requiring medical declarations for conditions like immersion-induced pulmonary oedema).” Source location Response from British Diving Safety Group
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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 Rewrite shore-cover guidance defining the roles and responsibilities of shore support.
Verbatim wording from the response “Agency | Role Definition & Guidance Structure | Current Action / Status
IANTD UK | Utilizes a historical code of conduct for instructors to bridge the gap between training standards and UK law. Demands a strict localized risk assessment for every operation. | Mandates that the surface brief must include explicit "eyes on the water" protocols, kit management, emergency plans, and verbal IPO awareness briefings.
ScotSAC | Mandates appropriate shore cover for all training activities, grounding the surface team's responsibilities directly in the dive's risk assessment. | The exact text detailing the specific roles and responsibilities of Shore Cover is currently undergoing a comprehensive rewrite.
SAA | Uses a Dive Marshal framework, assigning this individual complete responsibility for the dive team and the monitoring of divers for the day.” Source location Response from British Diving Safety Group
Open published response
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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 Form a working group to define recommended qualifications and good practices for shore cover.
Verbatim wording from the response “As BDSG we will put together a working group to define a set of recommendations of qualifications and good practices for all shore cover” Source location Response from British Diving Safety Group
Open published response
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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
Open published response
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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 Review Dive Management guidance to address the concern that shore support should maintain eyes on the water.
Verbatim wording from the response “Report #3:
Agency Response
BSAC
Role Definition & Guidance Structure
Uses 'BSAC Safe Diving Practices' code of conduct which includes having an appropriate dynamic risk assessment and a suitable Dive Management. Dive Management is integral to the BSAC Diver Training Programme training expanded on with each diver grade.” Source location Response from British Diving Safety Group
Open published response
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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
Open published response
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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 Implement a UK-specific addendum training SSI professional trainers on UK Diving at Work Regulations and Approved Code of Practice requirements.
Verbatim wording from the response “Organization | Volunteer Protocols & Project Awareness | Medical Screening & Enforcement Standards
IANTD | No separate standards exist for project volunteers. Duty of care and qualification requirements are left entirely to the subjective inclinations of individual project organizers. | Dependent on localized project risk assessments and task loading. All professional members must upload HSE medicals annually.
SSI | Advises UK commercial facilities that all team members should have HSE medicals, as it is highly unlikely a commercial business can legally escape the DWR. | All professionals must upload a doctor-signed medical clearance annually. SSI is implementing a UK-specific addendum to explicitly train instructors on UK DWR laws and ACOPs.
PADI | Provides summaries of HSE rules upon instructor qualification.” Source location Response from British Diving Safety Group
Open published response
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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
Open published response
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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 relationship between the deceased and the commercial diving project falls outside the organisation’s expertise to advise on.
Verbatim wording from the response “The relationship between the deceased and the commercial diving project he had volunteered to assist is not the type of event that the SAA have the expertise to advise on. Based on HSE guidance for “Using volunteers in diving at work projects” this is a complex area, and their advice is that the diving contractor should consider seek legal advice.” Source location Response from British Diving Safety Group
Open published response
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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 diving contractor should seek legal advice about applying volunteer safety requirements to the commercial diving project.
Verbatim wording from the response “The relationship between the deceased and the commercial diving project he had volunteered to assist is not the type of event that the SAA have the expertise to advise on. Based on HSE guidance for “Using volunteers in diving at work projects” this is a complex area, and their advice is that the diving contractor should consider seek legal advice.” Source location Response from British Diving Safety Group
Open published response
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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
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5 Jan 2022 Richard Paul Victor Sanders · Prevention of Future Deaths report Gloucestershire
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Concerns raised 3 Lack of awareness of immersion pulmonary oedema risks among people participating in diving View source Inefficient diver removal methods and techniques at the diving centre View source Failure to give sufficient consideration to a fitness-to-dive medical certificate as a prerequisite for diving participation View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 4
Action
Disseminate immersion pulmonary oedema risk information through conferences, incident reports, publications, websites, social media, webinars and water-safety engagement.
View source
Action
Update recreational diving medical questionnaires to include specific screening questions or references concerning immersion pulmonary oedema.
View source
Action
Amend training materials and training programmes to teach immersion pulmonary oedema causes, presentation and distinguishing features.
View source
Action
Produce and distribute guidance and refresher materials for divers and instructors addressing immersion pulmonary oedema.
View source See 1 more action
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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. The report was sent to British Diving Safety Group; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Diving Safety Group; that does not assign responsibility.
PFD Monitor interpretation Inefficient diver removal methods and techniques at the diving centre
Wider context from the report “3. Whether more efficient methods and/ techniques of diver removal from the water could be employed at the diving centre .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Diving Safety Group; that does not assign responsibility.
PFD Monitor interpretation Failure to give sufficient consideration to a fitness-to-dive medical certificate as a prerequisite for diving participation
Wider context from the report “2. Whether sufficient consideration has been given to the requirement for a “fitness to dive” medical certificate as a prerequisite to participation in diving activities .
” Open source report
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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
Open published response
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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 Update recreational diving medical questionnaires to include specific screening questions or references concerning immersion pulmonary oedema.
Verbatim wording from the response “Given that physical health is an important factor when diving, the two medical assessment forms have been updated in the past 2-3 years to include sections specifically to screen for a person’s susceptibility to IPO.” Source location 2022-0003-Response-from-British-Diving-Safety-Group_Published
Open published response
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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
Open published response
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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
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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 self-declaration questionnaires and referral arrangements are considered sufficient; a fitness-to-dive medical certificate is not required before participation.
Verbatim wording from the response “Current arrangements:
All the significant training agencies and the sports’ governing body, use one of two self-guided questionnaires to screen for medical conditions which require referral to a Diving Medical Referee for consultation and advice e.g. epileptics requiring medication or diabetics with recent hypoglycaemia are advised not to dive because of the risk of unexpected loss of consciousness which could be fatal underwater.” Source location 2022-0003-Response-from-British-Diving-Safety-Group_Published
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations