PFD report

Richard Paul Victor Sanders · Prevention of Future Deaths report

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Issued 5 Jan 2022•Gloucestershire

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.

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Concerns
3

Raised in this report

Recipients
4

Named on the report

Responses found
3

Of 4 recipients

Stated actions
19

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Lack of awareness of immersion pulmonary oedema risks among people participating in diving
    Part of recurring concern: Failure to reliably recognise and control immersion pulmonary oedema risks in diving
  2. Inefficient diver removal methods and techniques at the diving centre
    Part of recurring concern: Unsafe diving operations
  3. Failure to give sufficient consideration to a fitness-to-dive medical certificate as a prerequisite for diving participation
    Part of recurring concern: Inadequate individual risk assessment for activitiesPart of recurring concern: Unreliable medical fitness controls for divers
Responses linked to these concerns

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.10

  1. Action

    Require health declarations to identify IPO and other health factors influencing IPO risk before referral for medical advice or physical examination.

    Stated by United Kingdom Diving Medical Committee (UKDMCStated completedThe respondent said that this action was complete when they made their response on 10 January 2022.
  2. Action

    Consider new information affecting fitness-to-dive guidance at each committee meeting.

    Stated by United Kingdom Diving Medical Committee (UKDMCStated in progressThe respondent said that this action was in progress when they made their response on 10 January 2022.
  3. Action

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

    Stated by United Kingdom Diving Medical Committee (UKDMCStated in progressThe respondent said that this action was in progress when they made their response on 10 January 2022.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.6

  1. Position

    Reintroducing routine physical examinations would not identify independently diving people or those at risk because no specific test for IPO susceptibility exists.

    Stated by United Kingdom Diving Medical Committee (UKDMCUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

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

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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. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Unsafe diving operations.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Inadequate individual risk assessment for activities; Unreliable medical fitness controls for divers.

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

Require health declarations to identify IPO and other health factors influencing IPO risk before referral for medical advice or physical examination.

Verbatim wording from the response

“The UKDMC fitness assessment depends on a health declaration which determines whether a UKDMC Medical Referee (who will have received updates on IPO and its known risk factors) should be approached for advice or a physical examination. The health declaration asks specifically about IPO and also asks about other aspects of health which can influence risk of IPO. Routine annual physical examination has not been required for many years as it added no benefit to the assessment of those who did not declare any problems. Many divers have not declared problems, sometimes leading to fatality, but re-introduction of routine physical examination would not capture those who choose to dive independently and, due to lack of a specific test for susceptibility to IPO, would still miss individuals at risk.”

Source location

2022-0003-Response-from-St-Richards-Hospital_Published-1
Page 2 · response
Published 10 January 2022

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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

Consider new information affecting fitness-to-dive guidance at each committee meeting.

Verbatim wording from the response

“The UKDMC sets the medical requirements for diving for several national amateur diving organisations in the UK. Its members also advise the Health and Safety Executive on the medical requirements for commercial diving. The committee meets about 4 times per year and at every meeting it considers new information that might affect our guidance on fitness to dive.”

Source location

2022-0003-Response-from-St-Richards-Hospital_Published-1
Page 2 · response
Published 10 January 2022

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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

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

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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

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

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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

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

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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

Require suitably crewed safety boats at third-party operations based on controls identified through diving-operation risk assessments.

Verbatim wording from the response

“Moving forward any 3rd Party will have a suitably crewed safety boat in attendance which would derive from the diving operation risk assessment control measures, to provide a quick response to an incident and an efficient means of transferring a casualty to a suitable place of safety for treatment, if the incident location was appropriate to do so.”

Source location

2022-0003-Response-from-National-Diving-Activity-Centre_Published-1
Page 3 · response
Published 10 January 2022

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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
Page 4 · response
Published 10 January 2022

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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
Page 2 · 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

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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
Page 5 · response
Published 10 January 2022

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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

Reintroducing routine physical examinations would not identify independently diving people or those at risk because no specific test for IPO susceptibility exists.

Verbatim wording from the response

“Unlike flying, vocational driving or commercial diving, there is no legal requirement to have a medical examination for recreational diving. As a result, although some organisations insist that people diving with them satisfy the UKDMC requirements, people can dive independently without any medical examination.”

Source location

2022-0003-Response-from-St-Richards-Hospital_Published-1
Page 2 · response
Published 10 January 2022

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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

Reducing dishonest health declarations remains difficult because access to general practitioner records has proved unhelpful in some cases.

Verbatim wording from the response

“We do not condone dishonest declarations, not least because such behaviour endangers the diver’s buddy. We have considered ways that we can reduce dishonest declaration but even access to General Practitioner records has been unhelpful in some cases. This situation is not unique to diving. For instance, applicants make false medical declarations about eyesight, blackouts etc in order to retain a driving licence.”

Source location

2022-0003-Response-from-St-Richards-Hospital_Published-1
Page 2 · 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

A medical certificate requirement based on IPO risk is considered justifiable only if an equivalent requirement applies to open-water swimming.

Verbatim wording from the response

“Finally, more cases of IPO occur during open water swimming than in divers each year because there are more open water swimmers than divers. As a result, we believe that a requirement for a medical certificate for diving based on the risk of IPO could only be reasonably justified if the same was required for open water swimming.”

Source location

2022-0003-Response-from-St-Richards-Hospital_Published-1
Page 2 · 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

The existing health declaration and referral process is considered sufficient; routine annual physical examinations add no benefit for those declaring no problems.

Verbatim wording from the response

“The UKDMC fitness assessment depends on a health declaration which determines whether a UKDMC Medical Referee (who will have received updates on IPO and its known risk factors) should be approached for advice or a physical examination. The health declaration asks specifically about IPO and also asks about other aspects of health which can influence risk of IPO. Routine annual physical examination has not been required for many years as it added no benefit to the assessment of those who did not declare any problems. Many divers have not declared problems, sometimes leading to fatality, but re-introduction of routine physical examination would not capture those who choose to dive independently and, due to lack of a specific test for susceptibility to IPO, would still miss individuals at risk.”

Source location

2022-0003-Response-from-St-Richards-Hospital_Published-1
Page 2 · 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

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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
Page 6 · response
Published 10 January 2022

Open published response

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.9

  1. 1

    Educate UKDMC medical referees about IPO through the Google group and diving medicine conferences.

    Stated by United Kingdom Diving Medical Committee (UKDMCStated completedThe respondent said that this action was complete when they made their response on 10 January 2022.
  2. 2

    Engage the Royal College of Pathologists to publish an article on diving-related diseases, including IPO, in its magazine.

    Stated by United Kingdom Diving Medical Committee (UKDMCStated in progressThe respondent said that this action was in progress when they made their response on 10 January 2022.
  3. 3

    Continue researching IPO and publish findings in medical literature to educate doctors.

    Stated by United Kingdom Diving Medical Committee (UKDMCStated in progressThe respondent said that this action was in progress when they made their response on 10 January 2022.
  4. 4

    Send the Chief Coroner an information sheet explaining difficulties distinguishing IPO and post-mortem decompression artefact in diving deaths.

    Stated by United Kingdom Diving Medical Committee (UKDMCStated completedThe respondent said that this action was complete when they made their response on 10 January 2022.
  5. 5

    Make immersion pulmonary oedema information available to general practitioners and diving medical examiners.

    Stated by British Diving Safety GroupStated completedThe respondent said that this action was complete when they made their response on 10 January 2022.
  6. 6

    Provide coroners and pathologists with guidance and materials supporting diagnosis of immersion pulmonary oedema in diving fatalities.

    Stated by British Diving Safety GroupStated completedThe respondent said that this action was complete when they made their response on 10 January 2022.
  7. 7

    Continue investigating and monitoring immersion pulmonary oedema through recurring meetings, member action points and progress reporting.

    Stated by British Diving Safety GroupStated in progressThe respondent said that this action was in progress when they made their response on 10 January 2022.
  8. 8

    Create and continue compiling an incident evidence-preservation pack covering equipment shutdown, device interrogation and witness information.

    Stated by British Diving Safety GroupStated in progressThe respondent said that this action was in progress when they made their response on 10 January 2022.
  9. 9

    Continue reviewing historic diving incidents to identify cases involving immersion pulmonary oedema.

    Stated by British Diving Safety GroupStated in progressThe respondent said that this action was in progress when they made their response on 10 January 2022.

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

Educate UKDMC medical referees about IPO through the Google group and diving medicine conferences.

Verbatim wording from the response

“• We educate our own medical referees via our Google-group and at our conferences. There have been lectures on IPO at every diving medicine conference we have held in the last 10 years.”

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

Engage the Royal College of Pathologists to publish an article on diving-related diseases, including IPO, in its magazine.

Verbatim wording from the response

“• We have spoken to the Royal College of Pathologists in order to publish an article on diving related diseases, including IPO, in the College’s magazine to increase awareness of IPO amongst pathologists. o this was prompted by concern that some inquests have reached inappropriate findings in the case of diving deaths because Home Office pathologists and Coroners have insufficient knowledge of diving related illness including IPO. o we sent the Chief Coroner a one page information sheet which explains some of the difficulties in determining causes of diving related deaths when there is”

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

Continue researching IPO and publish findings in medical literature to educate doctors.

Verbatim wording from the response

“• We continue research into IPO and publish our findings in the medical literature to educate doctors throughout the world.”

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

Send the Chief Coroner an information sheet explaining difficulties distinguishing IPO and post-mortem decompression artefact in diving deaths.

Verbatim wording from the response

“• We have spoken to the Royal College of Pathologists in order to publish an article on diving related diseases, including IPO, in the College’s magazine to increase awareness of IPO amongst pathologists. o this was prompted by concern that some inquests have reached inappropriate findings in the case of diving deaths because Home Office pathologists and Coroners have insufficient knowledge of diving related illness including IPO. o we sent the Chief Coroner a one page information sheet which explains some of the difficulties in determining causes of diving related deaths when there is”

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

Make immersion pulmonary oedema information available to general practitioners and diving medical examiners.

Verbatim wording from the response

“Information about IPO: UK Diver Medical Committee paper on IPO for UK divers is made available by the training agencies to pass on to their GPs and Diving Medical Examiners.”

Source location

2022-0003-Response-from-British-Diving-Safety-Group_Published
Page 7 · 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 coroners and pathologists with guidance and materials supporting diagnosis of immersion pulmonary oedema in diving fatalities.

Verbatim wording from the response

“• Coroners and Pathologists are furnished with Dr ████████ short guide to diagnosis of IPO as a factor in diving fatalities. More detailed explanations and materials are also available.”

Source location

2022-0003-Response-from-British-Diving-Safety-Group_Published
Page 8 · 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

Continue investigating and monitoring immersion pulmonary oedema through recurring meetings, member action points and progress reporting.

Verbatim wording from the response

“When did the BDSG begin discussing the risks of IPO? The BDSG and its members first discussed IPO on 10th November 2016. At that meeting, the BSAC officer responsible for preparing the National Diving Incident Report presented the report which raised concerns based on the research undertaken by Dr ████████ (who we understand gave evidence at the inquest in which the Regulation 28 report arises), that IPO may have been a significant factor in diving fatalities. We agreed at that time that further investigation and monitoring was necessary.”

Source location

2022-0003-Response-from-British-Diving-Safety-Group_Published
Page 2 · 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

Create and continue compiling an incident evidence-preservation pack covering equipment shutdown, device interrogation and witness information.

Verbatim wording from the response

“BDSG – Preservation of Evidence: The BDSG has created, and is continuing to compile a pack for use at an incident to help preserve evidence.”

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

Continue reviewing historic diving incidents to identify cases involving immersion pulmonary oedema.

Verbatim wording from the response

“BDSG’s concern The BDSG is concerned that the number of IPO cases has been greatly understated. A review of historic incidents is being carried out and the “IPO implicated” number shown below are cases where there is a clear indication of IPO involvement. That review is continuing, so the number where IPO was implicated is likely to increase.”

Source location

2022-0003-Response-from-British-Diving-Safety-Group_Published
Page 3 · response
Published 10 January 2022

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026