Issued 16 Sep 2016•Leicester City and South Leicestershire
Report record
Published report and response evidence
This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.
On 27th April 2015 I commenced an investigation into the death of Denis William Patrick Cronin. The Inquest concluded on 8th September 2016.
The Coroners Conclusion was: Narrative: Denis Cronin attended Stoney Cove on 26th April 2015 as part of a group of divers from, and under the instruction and guidance of, Dulwich Dive Club with the purpose of practicing skills as part of his Sports Diver Course. Those organising and planning the dives on behalf of Dulwich Dive Club did not carry out a sufficient risk assessment, follow detailed guidance by BSAC or fully instruct Mr Cronin and / or his buddy. As a result, the dive took place in a way it should not have and a foreseeable risk of free flow occurred. Nevertheless, the situation was retrieved and Mr Cronin and his buddy were able to complete their ascent to the surface. However, at the surface Mr Cronin was struggling and unable to release his weight belt and although his buddy was correctly holding on to him Mr Cronin turned and swam away from him. Had he been able to release his belt, remained with his buddy and used the alternative air supply available to him, on a balance of probabilities he would have been rescued and survived.
Cause of death:
1a. Drowning
Circumstances of the death
Denis Cronin attended Stoney Cove (a diving site run by Stoney Cove Marine Trials Limited) on 26th April 2015 as part of a group of divers from, and under the instruction and guidance of, Dulwich Dive Club with the purpose of practicing skills as part of his Sports Diver Course. Those organising and planning the dives on behalf of Dulwich Dive Club did not carry out a sufficient risk assessment, follow detailed guidance by BSAC or fully instruct Mr Cronin and / or his buddy. As a result, the dive took place in a way it should not have and a foreseeable risk of free flow occurred. Nevertheless, the situation was retrieved and Mr Cronin and his buddy were able to complete their ascent to the surface. However, at the surface Mr Cronin was struggling and unable to release his weight belt and although his buddy was correctly holding on to him Mr Cronin turned and swam away from him. Had he been able to release his belt, remained with his buddy and used the alternative air supply available to him, on a balance of probabilities he would have been rescued and survived.
Coroner’s concerns
1) No training record is kept to evidence when training / practice took place; 2) Training was not in accordance with BSAC Sports Diver training ; 3) The plan for the second dive was for Mr Cronin to inflate the DSMB from a depth of around 17 metres. It took place at 20 metres. The BSAC instructions for Sports Diver are for the exercise to be conducted at 10 metres. 4) A diver without the necessary qualifications and experience was permitted to teach Mr Cronin with no instruction otherwise. 5) No written risk assessments / templates were completed to ensure those responsible for the dive have focused their minds to relevant circumstances; 6) The dive was not properly planned. A Safety and Development Manager employed by BSAC said he would not have done the final dive in the way that it was planned and conducted. 7) Mr Cronin had previously dived to a maximum depth of 16.5yet he was permitted to dive to 20 metres after an 8 month gap since his last open water dive. 8) Signs containing important information and clearly displayed at several sites at the Dive Centre were not read. Evidence was heard that it was believed that there was not a need because it was not the first visit to the Dive Centre and a map of the site had been printed off the internet in advance of the visit. One witness said that if he had seen the signs then it would possibly have made him think twice about doing the DSMB inflation exercise on another day. 9) The belt configuration meant that there was a foreseeable risk that it could not easily be released.
Concerns and recipient responses
Select any concern, action or position to view the source wording.
Report evidence summary
Concerns raised9
Failure to match permitted dive depth to diver experience and currency
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.12
Action
Continue encouraging students and qualified divers to follow training and practise regularly with their chosen equipment configuration.
Stated byDulwich BSAC 102Stated in progressThe respondent said that this action was in progress when they made their response on 16 September 2016.
Action
Remind instructors to follow BSAC training-programme guidance.
Stated byDulwich BSAC 102Stated plannedThe respondent said that this action was planned when they made their response on 16 September 2016.
Action
Remind all instructors about required instruction and supervision levels.
Stated byDulwich BSAC 102Stated completedThe respondent said that this action was complete when they made their response on 16 September 2016.
Action
Develop a method to record partially completed diver training.
Stated byDulwich BSAC 102Stated plannedThe respondent said that this action was planned when they made their response on 16 September 2016.
Action
Remind instructors to follow Diver Training Programme guidance for skills through Instructor News.
Stated byBritish Sub-Aqua ClubStated plannedThe respondent said that this action was planned when they made their response on 16 September 2016.
Action
Introduce signed individual-skills records within the revised Diver Training Programme to improve training completion records.
Stated byBritish Sub-Aqua ClubStated plannedThe respondent said that this action was planned when they made their response on 16 September 2016.
Action
Continue educating divers and instructors about dive planning through member emails, instructor bulletins and SCUBA Magazine articles.
Stated byBritish Sub-Aqua ClubStated in progressThe respondent said that this action was in progress when they made their response on 16 September 2016.
Action
Distribute a table reminding instructors of qualification requirements for teaching each Diver Training grade.
Stated byBritish Sub-Aqua ClubStated plannedThe respondent said that this action was planned when they made their response on 16 September 2016.
Action
Develop a digital platform integrating training records so instructors, students, branches and BSAC can record skill completion online.
Stated byBritish Sub-Aqua ClubStated in progressThe respondent said that this action was in progress when they made their response on 16 September 2016.
Action
Review website risk-assessment information and assess interactive materials through the new digital platform.
Stated byBritish Sub-Aqua ClubStated plannedThe respondent said that this action was planned when they made their response on 16 September 2016.
Action
Remind instructors through Instructor News to teach weightbelt removal as required by the Diver Training Programme.
Stated byBritish Sub-Aqua ClubStated plannedThe respondent said that this action was planned when they made their response on 16 September 2016.
Action
Produce guidance explaining the importance of weightbelt removal.
Stated byBritish Sub-Aqua ClubStated plannedThe respondent said that this action was planned when they made their response on 16 September 2016.
Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.10
Position
Free-flow was not considered a special risk below five degrees Celsius, and existing cold-water regulators and briefing arrangements were considered adequate.
Stated byDulwich BSAC 102Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The second dive was considered safe because correct nitrogen calculations and surface-interval procedures complied with current guidelines.
Stated byDulwich BSAC 102Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Weight-belt and equipment configuration was considered a matter of personal choice because no governing guidelines exist and training covered weight removal.
Stated byDulwich BSAC 102Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Written risk assessments are not considered necessary at known sites because current guidelines and established dive-planning and briefing practices apply.
Stated byDulwich BSAC 102Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Site signs were considered awareness measures, while operators acknowledged their warnings were overly cautious for year-round cold-water DSMB practice.
Stated byBritish Sub-Aqua ClubDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Progressing from 16.5 to 20 metres after a gap was not considered unreasonable, and no evidence showed the recommendation posed diver risk.
Stated byBritish Sub-Aqua ClubDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The weightbelt and BCD configuration was considered uncommon as a safety concern.
Stated byBritish Sub-Aqua ClubDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Conducting Sports Diver lessons out of sequence was considered reasonable because prerequisite skills are taught at Ocean Diver level.
Stated byBritish Sub-Aqua ClubDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing training requires practising removal of divers’ own and buddies’ weightbelts at every stage and encourages regular practice.
Stated byBritish Sub-Aqua ClubExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
No single or simple message could highlight the specific dive-planning concern because dives vary with conditions and individual skills.
Stated byBritish Sub-Aqua ClubUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Other statements in published responses
These actions and other statements could not be clearly connected to one concern in this report.
Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4
1
Seek further BSAC guidance on differing approaches to conducting dives.
Stated byDulwich BSAC 102Stated plannedThe respondent said that this action was planned when they made their response on 16 September 2016.
2
Seek clear guidance on best practice for DSMB use.
Stated byDulwich BSAC 102Stated plannedThe respondent said that this action was planned when they made their response on 16 September 2016.
3
Seek clarification from BSAC on the sequencing of lessons.
Stated byDulwich BSAC 102Stated plannedThe respondent said that this action was planned when they made their response on 16 September 2016.
4
Advise all members on further BSAC guidance about differing approaches to conducting dives.
Stated byDulwich BSAC 102Stated plannedThe respondent said that this action was planned when they made their response on 16 September 2016.
Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2
1
BSAC is responsible for providing the club’s training, advice and guidance on the proposed safety changes.
Stated byDulwich BSAC 102Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
2
The club cannot effectively incorporate many proposed safety changes without further guidance.
Stated byDulwich BSAC 102Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
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