BENJAMIN DAVID MCQUEEN · Prevention of Future Deaths report

On 26 November 2018 the Senior Coroner for Dorset commenced an investigation into the death of BENJAMIN DAVID MCQUEEN, aged 26. The investigation concluded at the end of the inquest held by me as nominated Judge Coroner from 10 to 28 July 2023. The conclusion of the inquest was as follows:

Medical Cause of Death
Ia Drowning

How, when, and where, and for investigations where section 5(2) of the Coroners and Justice Act 2009 applies, in what circumstances the deceased came by his or her death.

On 14 November 2018, Benjamin McQueen drowned during a military diving exercise in Portland Harbour, Dorset. He experienced complications during the dive. He carried out one or more authorised emergency drills which would have rapidly depleted the supply from his breathing apparatus. He was recovered from the sea bed from a depth of about 18 metres, but despite appropriate attempts at Cardio Pulmonary Resuscitation he could not be revived and his death was declared at 19.17.

Conclusion of the Coroner as to the death

Short form conclusion: Accident during arduous military training for operations with an elite unit.

Additional narrative conclusion: Ben’s Unit collectively took diver safety seriously and conscientiously. However, his death was contributed to by the following failures:
(1) Not topping up breathable gas levels between the two dives;
(2) The lack of a training requirement for all signals to be acknowledged;
(3) Inadequate risk assessment for the combined use of the equipment on the exercise which failed to identify mitigating measures for the risks arising (insistence on careful progression; shallower water and ensuring breathable gas was topped up);
(4) A marked and inappropriate increase in the rate of training progression in the second phase of the exercise;
(5) Insufficiently firm instruction on when student divers should surface.

It is also possible (but cannot be said to be probable) that his death was contributed to by:
(1) Limitations in training in the Emergency Ascent Drill, including the lack of reference to the use of the Buoyancy Control Jacket to ascend;
(2) Not specifically training dive students to check their cylinder pressure after the trouble drill and not specifically warning about the use of breathable gas it could use up;
(3) Inadequate consideration of the risk of a lost diver in selecting the most appropriate cylinder for the stand-by diver;
(4) Failing to ensure a full and rapid de-brief of all of the surviving divers who surfaced in choosing where to deploy the stand-by diver;
(5) The lack of formal authorisation from Headquarters for some of the equipment to be used on the exercise because following the correct procedure may have highlighted the deficiencies in the risk assessments;
(6) The resource limitations leading to a relative lack of proactive engagement in the Chain of Command between the levels of the Dive Cell Co-ordinator and the head of the training department.

The circumstances of the death are briefly summarised in the text above. Detailed factual findings in Security Sensitive form are held by MOD and I request that you should have regard to the full Security Sensitive factual findings.

(1) A stand-by diver was present at the dive exercise and he was deployed to try to find and rescue Ben. However, the stand-by diver had to surface having run out of breathable gas before Ben was found. A spare breathing apparatus cylinder was not carried in the safety boat for the stand-by diver (or other divers) to use in the event that the stand-by diver’s main cylinder ran out.

(2) The progression of the dive training in which Ben was engaged was safety-critical. The progression of training was accelerated for several reasons, one of which was a visit by a high-ranking naval officer. The concern of the instructing staff was to polish the drills ahead of that visit and to take the pressure off the dive students by allowing them to practise the dive with relevant equipment ahead of the visit. This acceleration of safety-critical training in part because of such a visit was not appropriate.

(3) Ben was lifted unconscious from the sea bed and Cardio Pulmonary Resuscitation was immediately started. A defibrillator was also applied, but this was only available because it was carried by a Harbour Patrol vessel which came to assist. I am concerned that in such safety-critical military diving training, the dive support staff did not have available to them a defibrillator of their own either on the supporting safety boats or on land. This did not cause or contribute to Ben’s death but could lead to future fatalities.

(4) There is an inconsistency regarding the minimum safety pressure level for the relevant diver’s breathing apparatus as between the maintenance manual which DE&S is responsible and all other policy and safety guidance.