Angela Kearn
PFD Report
Partially Responded
Ref: 2023-0109Deceased
2 of 4 responded · Over 2 years old
Sent To
Response Status
Responses
2 of 4
56-Day Deadline
9 May 2023
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
Awareness of Immersion Pulmonary Oedema in the medical profession: i.) Concerns were raised by the medical witnesses that there is very little awareness of Immersion Pulmonary Oedema in the medical profession and that it is not addressed in medical training, as a consequence, it can be missed by those treating the condition and is often mistaken for drowning.
The Full Face Mask ii.) At the time that the Easybreath full face snorkel mask was developed by Decathlon there were no United Kingdom or European Standards which were applicable to a full face snorkelling mask.
iii.) In the course of its development, Decathlon commissioned a number of tests to be undertaken on it, but it was accepted in evidence that the tests undertaken did not replicate the conditions of the use of the mask by the general public.
iv.) Decathlon have sold over 16 million of the masks. Other such masks are also on the market.
v.) The Decathlon usage instructions for the full face mask, contained in small print, have been amended over time. From the 17th August 2015 the instructions included a warning that you must make sure that you are in good physical condition before snorkelling and that the mask is not suitable for swimming.
vi.) Further tests were undertaken and an Ergomedical report considered the issue of whether use of the mask and inhalation through the mask’s dead space gave rise to excess carbon dioxide inhalation. The report concluded “we strongly recommend to advise against wearing Easybreath masks to people who suffer from underlying cardio-respiratory conditions.”
vii.) As a result, Decathlon amended their instructions for use to include that the mask should not be used if the user has unstable cardio-respiratory pathologies, that the mask is to be used under conditions of submaximal exercise (mild to moderate) and that it is not suitable for active swimming.
viii.) Development of a United Kingdom standard in relation to this type of mask is now being put in train but has not yet begun and is likely to take some time.
ix.) Decathlon have recently updated their website in the United Kingdom to include the following, “It is not recommended to use this product if you have any ongoing respiratory or cardiovascular issues including but not limited to chest infection, asthma, high/raised blood pressure (hypertension), heart disease or angina etc. If you have any doubts or questions relating to this please check with your medical practitioner." The same additional wording is being translated and added to all websites of the company.
x.) The packaging of the mask has been revised to show a pictogram to warn against use of the mask by those with heart or other cardiovascular conditions.
xi.) The concern is that many million of the full face masks have been sold and the safety concerns about their use by those with ongoing cardiovascular and respiratory issues has not been widely publicised or brought to the attention of those who already own the masks. Those purchased before 2017 had no warning is relation to these matters and the warning included in the instructions from 2017 inwards was not prominent nor sufficient to alert prospective purchasers to the hazards of use which have now been identified.
i/
The Full Face Mask ii.) At the time that the Easybreath full face snorkel mask was developed by Decathlon there were no United Kingdom or European Standards which were applicable to a full face snorkelling mask.
iii.) In the course of its development, Decathlon commissioned a number of tests to be undertaken on it, but it was accepted in evidence that the tests undertaken did not replicate the conditions of the use of the mask by the general public.
iv.) Decathlon have sold over 16 million of the masks. Other such masks are also on the market.
v.) The Decathlon usage instructions for the full face mask, contained in small print, have been amended over time. From the 17th August 2015 the instructions included a warning that you must make sure that you are in good physical condition before snorkelling and that the mask is not suitable for swimming.
vi.) Further tests were undertaken and an Ergomedical report considered the issue of whether use of the mask and inhalation through the mask’s dead space gave rise to excess carbon dioxide inhalation. The report concluded “we strongly recommend to advise against wearing Easybreath masks to people who suffer from underlying cardio-respiratory conditions.”
vii.) As a result, Decathlon amended their instructions for use to include that the mask should not be used if the user has unstable cardio-respiratory pathologies, that the mask is to be used under conditions of submaximal exercise (mild to moderate) and that it is not suitable for active swimming.
viii.) Development of a United Kingdom standard in relation to this type of mask is now being put in train but has not yet begun and is likely to take some time.
ix.) Decathlon have recently updated their website in the United Kingdom to include the following, “It is not recommended to use this product if you have any ongoing respiratory or cardiovascular issues including but not limited to chest infection, asthma, high/raised blood pressure (hypertension), heart disease or angina etc. If you have any doubts or questions relating to this please check with your medical practitioner." The same additional wording is being translated and added to all websites of the company.
x.) The packaging of the mask has been revised to show a pictogram to warn against use of the mask by those with heart or other cardiovascular conditions.
xi.) The concern is that many million of the full face masks have been sold and the safety concerns about their use by those with ongoing cardiovascular and respiratory issues has not been widely publicised or brought to the attention of those who already own the masks. Those purchased before 2017 had no warning is relation to these matters and the warning included in the instructions from 2017 inwards was not prominent nor sufficient to alert prospective purchasers to the hazards of use which have now been identified.
i/
Responses
National Trading Standards states it is unable to act on the issues raised as product safety does not fall within its scope, and recommends sending the report to the Office for Product Safety and Standards.
AI summary
View full response
Dear Ms Topping,
Regulation 28 Report – Angela Kearn
We received the above report on 29/3/23. has asked me to respond on his behalf. Firstly we would like to express our condolences to the family of Ms Kearn.
National Trading Standards (NTS) is not able to act on the issues raised in this report. NTS is a grant giving body that utilises Government grants to commission specified elements of Trading Standards related work from local authorities. Product safety does not fall within the scope of NTS. We do not receive any grants to commission work in this area. Issues surrounding product recalls and the Government lead for the safety of consumer products lies with the Office for Product Safety and Standards (part of the Department for Business and Trade). They work with local authorities on product recalls and we would recommend that, if it has not already been sent to them, that this report is sent to the Chief Executive of OPSS to respond.
I am sorry that NTS is unable to assist directly.
Regulation 28 Report – Angela Kearn
We received the above report on 29/3/23. has asked me to respond on his behalf. Firstly we would like to express our condolences to the family of Ms Kearn.
National Trading Standards (NTS) is not able to act on the issues raised in this report. NTS is a grant giving body that utilises Government grants to commission specified elements of Trading Standards related work from local authorities. Product safety does not fall within the scope of NTS. We do not receive any grants to commission work in this area. Issues surrounding product recalls and the Government lead for the safety of consumer products lies with the Office for Product Safety and Standards (part of the Department for Business and Trade). They work with local authorities on product recalls and we would recommend that, if it has not already been sent to them, that this report is sent to the Chief Executive of OPSS to respond.
I am sorry that NTS is unable to assist directly.
The GMC states that current medical training standards equip doctors to assess complex emergencies and consider differential diagnoses, including rare conditions like Immersion Pulmonary Oedema. They believe no further specific education and training intervention for IPO is required.
AI summary
View full response
Dear Miss Topping
Regulation 28 report Angela Kearn
I am responding on behalf of Professor .
I am deeply sorry to hear of the untimely and tragic circumstances of Angela Jean Kearns’ death. I extend my deepest condolences to Angela’s family and those impacted by her death.
Following an incident in Egypt, your report has raised concerns about awareness of ‘Immersion Pulmonary Oedema’ in the medical profession and that this condition is not specifically addressed in medical training.
Through our standards and quality assurance of medical education and training we ensure that doctors in the UK are equipped with professional behaviours, knowledge, and skills to competently assess complex and uncertain acute and emergency situations. In addition, through professional clinical reasoning doctors are able to consider relevant differential diagnoses and manage acute medical emergencies including identifying people at high risk due to underlying comorbidities (such as Angela’s age and her history with hypertension).
I hope the information above assures you that clinical knowledge and training is being assessed in areas that may intersect with Immersion Pulmonary Oedema and therefore if a doctor in the UK was to encounter a patient with this rare condition, they should have the tools and knowledge to be able to diagnose the condition and proceed accordingly with treatment.
Whilst it is not the role of the GMC to comment on specific clinical practice, Immersion Pulmonary Oedema is a rare condition and its emergency presentation may be similar to other medical emergencies. Its immediate management will also be similar and therefore we feel at this stage no further specific education and training intervention would be required. Institutions such as the Medical Royal Colleges may be able to provide you with information related to the details for a process to identify and develop areas where learning is needed and can be shared in postgraduate training across the relevant specialties and subspecialties.
gmc.uk.org 2
I note that this case happened in Egypt. We are not able to comment on the level of training or the medical education system in Egypt as that country is outside our jurisdiction.
The GMC is committed to work with others in the health care sectors to improve training of the professionals we regulate so that doctors are better equipped with dealing with the variety of healthcare concerns and demands within the UK. To provide some context to medical education and training in the UK, I hope the attached annexe is helpful to you.
Regulation 28 report Angela Kearn
I am responding on behalf of Professor .
I am deeply sorry to hear of the untimely and tragic circumstances of Angela Jean Kearns’ death. I extend my deepest condolences to Angela’s family and those impacted by her death.
Following an incident in Egypt, your report has raised concerns about awareness of ‘Immersion Pulmonary Oedema’ in the medical profession and that this condition is not specifically addressed in medical training.
Through our standards and quality assurance of medical education and training we ensure that doctors in the UK are equipped with professional behaviours, knowledge, and skills to competently assess complex and uncertain acute and emergency situations. In addition, through professional clinical reasoning doctors are able to consider relevant differential diagnoses and manage acute medical emergencies including identifying people at high risk due to underlying comorbidities (such as Angela’s age and her history with hypertension).
I hope the information above assures you that clinical knowledge and training is being assessed in areas that may intersect with Immersion Pulmonary Oedema and therefore if a doctor in the UK was to encounter a patient with this rare condition, they should have the tools and knowledge to be able to diagnose the condition and proceed accordingly with treatment.
Whilst it is not the role of the GMC to comment on specific clinical practice, Immersion Pulmonary Oedema is a rare condition and its emergency presentation may be similar to other medical emergencies. Its immediate management will also be similar and therefore we feel at this stage no further specific education and training intervention would be required. Institutions such as the Medical Royal Colleges may be able to provide you with information related to the details for a process to identify and develop areas where learning is needed and can be shared in postgraduate training across the relevant specialties and subspecialties.
gmc.uk.org 2
I note that this case happened in Egypt. We are not able to comment on the level of training or the medical education system in Egypt as that country is outside our jurisdiction.
The GMC is committed to work with others in the health care sectors to improve training of the professionals we regulate so that doctors are better equipped with dealing with the variety of healthcare concerns and demands within the UK. To provide some context to medical education and training in the UK, I hope the attached annexe is helpful to you.
Report Sections
Investigation and Inquest
Following an investigation opened on the 2nd March 2020 and an inquest opened on the 5th March 2020 the inquest was concluded on the 20th December 2022. The cause of death was: 1a.) Immersion Pulmonary Oedema II.) Hypertension and Menopause treated by Hormone Replacement Therapy The narrative conclusion was: Angela Jean Kearn was suffering from hypertension and taking hormone replacement therapy. On the 13th January 2020 she was snorkelling using a full face mask. She developed immersion pulmonary oedema and died at the Nile Hospial, Hurghada Egypt. Hypertension, hormone replacement therapy and the use of the full face mask each more than minimally contributed to the death
Circumstances of the Death
i.) Angela Kearn was aged 63 when she died. She had recently been diagnosed with hypertension which was being treated with atenolol. She was also taking hormone replacement therapy.
ii.) For the previous 5 years she had been using a Decathlon Easybreath full face snorkel mask when on holiday.
iii.) On the 13th January 2020 she was snorkelling using the full face mask when she expressed concerns and was accompanied back to the beach. She collapsed and died.
iv.) Expert evidence at the inquest identified immersion pulmonary oedema as the cause of the death. This is caused by the build-up of fluid in the lungs as a result of an increase in pulmonary capillary pressure caused by water pressure when the chest is submerged. This is exacerbated by hypertension and hormone replacement therapy. Negative pressure in the lungs causes fluid from the blood vessels to be drawn into the lungs.
v.) The use of a full face snorkel mask contributed to the death in two ways:
a.) because negative pressure in the lungs is increased as a result of the increased effort of breathing caused by inhalation through the snorkel tube and mask, and
b.) because respiratory effort is increased by the inhalation of elevated carbon dioxide levels caused by inhaling air drawn through a dead space in the mask. Both exacerbate the negative pressure in the lungs and increase the effects of immersion pulmonary oedema.
ii.) For the previous 5 years she had been using a Decathlon Easybreath full face snorkel mask when on holiday.
iii.) On the 13th January 2020 she was snorkelling using the full face mask when she expressed concerns and was accompanied back to the beach. She collapsed and died.
iv.) Expert evidence at the inquest identified immersion pulmonary oedema as the cause of the death. This is caused by the build-up of fluid in the lungs as a result of an increase in pulmonary capillary pressure caused by water pressure when the chest is submerged. This is exacerbated by hypertension and hormone replacement therapy. Negative pressure in the lungs causes fluid from the blood vessels to be drawn into the lungs.
v.) The use of a full face snorkel mask contributed to the death in two ways:
a.) because negative pressure in the lungs is increased as a result of the increased effort of breathing caused by inhalation through the snorkel tube and mask, and
b.) because respiratory effort is increased by the inhalation of elevated carbon dioxide levels caused by inhaling air drawn through a dead space in the mask. Both exacerbate the negative pressure in the lungs and increase the effects of immersion pulmonary oedema.
Copies Sent To
Decathlon UK
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Equipment for BA communication in high-rise buildings
Grenfell Tower Inquiry
Emergency responder equipment training
Command support system operational on all units
Grenfell Tower Inquiry
Emergency responder equipment training
Equip fire services to receive electronic plans
Grenfell Tower Inquiry
Emergency responder equipment training
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.