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Coronial Findings OFFICE OF THE STATE CORONER FINDING OF INQUEST CITATION: Inquest into the death of Stephen James Broe TITLE OF COURT: Coroner’s Court JURISDICTION: Brisbane FILE NO(s): COR 717/05 (3) DELIVERED ON: 24 April 2009 DELIVERED AT: Brisbane HEARING DATE(s): 17 October 2008, 9-13 March & 17-18 March 2009 FINDINGS OF: Mr Michael Barnes, State Coroner CATCHWORDS: CORONERS: Inquest, deep technical recreation diving, decompression illness, investigation of diving deaths REPRESENTATION: Counsel Assisting: Mr Peter Johns Dr Greg Emerson: Mr David Tait SC with Mr Andrew Luchich (instructed by Avant) Professional Association of Mr Richard Douglas SC with Mr Damien Diving Instructors (PADI); Atkinson (instructed by Herbert Geer) Billionaires in Business Pty Ltd; Mr Mark Thomas; Dr Alexandra Broe: Mr Mark O’Sullivan (instructed by Tutt Down McKeering Solicitors) Table of contents Introduction ......................................................................................................1 The evidence ...................................................................................................1 Social history................................................................................................1 Medical history .............................................................................................2 Diving history................................................................................................3 What is technical diving?..............................................................................3 Regulatory instruments and organisations ...................................................4 Fitness to dive ..............................................................................................5 Requirement for medicals.........................................................................5 Standard to be applied..............................................................................5 The dive medicals undertaken by Dr Broe ...................................................6 Expert Evidence on risk factors....................................................................7 Age ...........................................................................................................7 Obesity......................................................................................................7 Conn’s Syndrome and hypertension.........................................................8 Obstructive sleep apnoea .........................................................................8 Phenytoin..................................................................................................9 Role of the dive medical practitioner ............................................................9 Conclusion as to adequacy of the diving examination ............................10 The DSAT Tec Deep Dive Course .............................................................11 Informed consent ....................................................................................11 Prodive....................................................................................................12 Progress through course.........................................................................12 The incident weekend.............................................................................12 The planned dives ..................................................................................13 Calculation of decompression schedules................................................13 Conclusion as to use of dive profile software..........................................15 Sunday 27 March 2005...........................................................................15 Monday 28 March 2008 – the third Dive .................................................16 Reverse dive profiles ..............................................................................16 Conclusion as to reverse dive profiles ....................................................17 Spacing of the dives ...............................................................................17 Conclusion concerning dive schedules...................................................18 Filling of air and decompression gas cylinders .......................................18 Conclusion as to gas mixing ...................................................................19 The final dive..............................................................................................19 The planned dive profile .........................................................................19 Adherence to the planned dive profile ....................................................19 Depth ......................................................................................................20 Conclusion as to dive profile and depth ..................................................21 Exiting the water .....................................................................................21 First aid...................................................................................................21 The Investigation ........................................................................................22 Queensland Police Service investigation................................................22 WH&SQ investigation .............................................................................22 The cause of death.....................................................................................23 The autopsy evidence.............................................................................23 Other expert opinions .............................................................................24 Conclusion as to cause of death.............................................................25 Prosecution arising from WH&S Investigation ...............................................25 Responsibility for the death ........................................................................26 Section 45 findings.........................................................................................26 Identity ....................................................................................................26 Place of death.........................................................................................26 Date of death ..........................................................................................26 Cause of death .......................................................................................26 Section 46 recommendations ........................................................................26 Investigating diving deaths .........................................................................27 Recommendation 1 – Review of QPS – WH&SQ MOU..........................27 CT scanning of deceased divers ................................................................27 Recommendation 2 – Protocol for CT scanning of deceased divers ......27 Unloading deep divers................................................................................27 Recommendation 3 – Review of industry code of practice .....................28 Dive medicals .............................................................................................28 Recommendation 4 – Review of dive medical forms and guidelines ......28 Referral to the Medical Board ........................................................................28 The Coroners Act 2003 provides in s 45 that when an inquest is held, the coroner’s written findings must be given to the family of the person who died, each of the persons or organisations granted leave to appear at the inquest and to various specified officials with responsibility for the justice system or other agencies with responsibility for the areas of administration referred to in any comments or recommendations. These are my findings in relation to the death of Stephen James Broe. They will be distributed in accordance with the requirements of the Act and posted on the web site of the Office of the State Coroner. Introduction Dr Stephen Broe was a highly accomplished medical doctor who had a passion for SCUBA diving. On 28 April 2005, shortly after midday, he emerged from the ocean a few kilometres north of Moreton Island and climbed onto a charter boat. He had just completed the final dive in a technical deep diving course he had been undertaking over the preceding couple of months. He almost immediately complained of burning pain in his chest and severe shortness of breath. Despite assistance from people on the boat, Dr Broe lapsed into unconsciousness and died a few minutes later. These findings: • confirm the identify of the deceased man and the time and place of his death; • determine the medical cause of his death; • consider whether Dr Broe was appropriately certified fit to undertake the diving course that led to his death; • consider whether the two dives undertaken on the day of Dr Broe’s death were undertaken in accordance with appropriate industry standards, including in particular whether; o the sequence of dive depths; o the time intervals between them; and o the decompression stops planned and executed were within acceptable limits. • consider whether changes to the manner in which Dr Broe’s equipment was brought back onto the dive boat at the conclusion of the dive could improve public health and safety. • examine how the gas mix in his NITROX cylinder came to be other than what was intended. The evidence Social history Stephen James Broe was born
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