DSB BRITISH DIVING SAFETY GROUP Working together to make recreational scuba diving safer Regulation 28 report - H.M. Senior Coroner for Gloucestershire - BDSG response This document is prepared by the British Diving Safety Group ("BDSG" through its members) in response to a Regulation 28 report issued by HM Senior Coroner for Gloucestershire, Ms Katy Skerrett, dated 5 January 2022. Members include: Training Agencies:
• BSAC (British Sub-Aqua Club)
• IANTD (International Association of Nitrox and Technical Divers)
• PADI (Professional Association of Diving Instructors)
• PSAI (Professional Scuba Association International)
• SAA (.Sub Aqua Association)
• ScotSAC (Scottish Sub-Aqua Club)
• 551 (Scuba Schools International)
• TOI/SDI (Technical Diving International/Scuba Diving International) What is the BDSG?: Other Diving Organisations:
• BDSG (British Diving Safety Group)
• DDRC (Diving Diseases Research Centre)
• DOST (Defence Diving Standards Team)
• IDEST (Inspectorate for Diving Equipment Servicing & Testing)
• MCA (Maritime and Coastguard Agency)
• RNLI (Royal National Lifeboat Institution)
• SITA (Scuba Industries Trade Association)
• UKDMC (UK Diving Medical Committee) The BDSG was formed in 2002 to promote and improve safety for amateur sub-aqua divers in the UK and when diving abroad. The BDSG is made up of representatives from organisations involved in training, regulatory, governance, diving medicine and support of amateur sub-aqua diving. Immersing yourself in a body of water is a hazardous activity, however, risks can be mitigated to reasonable and acceptable levels with proper training, well maintained equipment and an appropriate level of mental and physical fitness for the activity being undertaken. In spite of a great deal of work undertaken by BDSG and others to promote an understanding of the symptoms of Immersion Pulmonary Oedema (IPO) and how it tends to manifests itself in diving incidents, the overall impression of the BDSG members is that there exists a significant disparity between recreational divers' awareness of DCI (Decompression Illness) and their awareness of IPO.

Regulation 28 report H.M. Senior Coroner for Gloucestershire - BDSG response IPO: UKDMC - What is Immersion Pulmonary Oedema (JPO) IPO can occur whenever a person is immersed in a body of water. Some studies show that even very fit individuals such as tri-athletes, can suffer with IPO during the swim phase of their competitions. US Navy Seals have been found to suffer with IPO when they carry out long strenuous surface swims and in their cases, they often suffer the effect only in one lung because they swim "side-stroke", and the centroid of one lung is lower in the water than the other. 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. Pre-testing for IPO: There is no screening test that can definitively determine whether an individual will suffer from IPO, but there are a number of known factors which increase the likelihood of an individual being subject to IPO. Completing either the UHMS (Undersea and Hyperbaric Medical Society) or UKDMC (UK Diving Medical Committee) medical declaration form prior to any training/diving taking place helps in identifying the known risk factors. With respect to diving medicals, assessments and the self-declaration tools, the UK diving population, who are members of a club or training organisation are divided into two groups, BSAC/ScotSAC and SAA, use the UKDMC medical self­ assessment, while everyone else uses the UHMS tool. 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.

Regulation 28 report H.M. Senior Coroner for Gloucestershire - BDSG response The Matter of Concern #1: "Whether there is sufficient awareness of the risks & affects of Immersion Pulmonary Oedema (/PO) by those engaged and/or participating in the activity of diving?" Report #1: IPO was first discussed at the BDSG on 10th November 2016. It was agreed at that meeting, further investigation and monitoring was necessary. Since 2016, almost every meeting has included further discussions and updates on IPO, with specific action points for members. Those members tasked with action points are then required to report on their progress at the following meeting(s). The BDSG members believe that whilst IPO presents a significant risk to divers, fatalities can be prevented. However, it is difficult to build a convincing case to show the dangers of IPO and get people to acknowledge and take the risk seriously, without evidence to properly quantify the risk and the sheer scale of the issue. Furthermore, the BDSG members believe IPO has been the cause of death, or the provocative factor (the trigger that leads to death), in a number of diving fatalities, but may have been misdiagnosed as drowning or barotrauma. Dr certainly shares this view. 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. From the National Diving Incident Reports compiled since 1964:­ Total incidents: ...................... .. .............. ........... ..................................................... 8725 Confirmed IPO (not only the fatal case): ................................................................... 30 IPO implicated (undiagnosed, but show the key features of IPO): .. .. ...................... 183 In order to properly quantify the risk of IPO, it is imperative that the Police, who often take primacy of diving investigations, properly preserve and collate the necessary evidence to help Pathologists and Coroners make more accurate diagnoses and conclusions. Whilst the HSE (as they have a specialist and dedicated diving team) know how to preserve evidence properly in diving cases e.g. diving equipment, the Police do not have the requisite knowledge to do this and the BDSG members fear that vital evidence is often not gathered or overlooked. More accurate statistics will help build a convincing case that IPO is a significant and real danger- which in turn should make people take IPO much more seriously.

Regulation 28 report H.M. Senior Coroner for Gloucestershire - BDSG 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: BDSG Serious Accident Guide for Divers v1. 0 BDSG - General handling equipment post-incident General - Rebreather post-incident investigation guidelines Ambient Pressure (AP) - post-incident inspection guidelines RESA - Hollis Explorer SR Lockdown RESA - Hollis Prism2 - post-incident Jockdown RESA - KISS - post-incident procedure RESA - rEvo - post-incident investigation guidelines V1 . 1 RESA - Shearwater - post-incident guidelines The pack uses instructions drafted by the equipment manufacturer to describe how to shut down specific diving equipment safely and what information to collect and preserve. Safely shutting down complex closed circuit rebreather systems and interrogating the electronic monitoring devices is beyond the scope of a normal Police Officer. The pack also describes the types of evidence from witnesses that would be relevant to a Pathologist and Coroner in their determinations. E.g. " ... incident began at depth and the casualty gave an out of gas signal ... ", " ... the casualty rejected their primary and alternate air supplies ... ". " ... casualty made a rapid ascent to the surface after an out of gas signal..", " ... we found N bar of gas in the system ... ", " ... checks showed gas was available and no equipment faults ... " etc. BDSG "lookback test": We've used this report as an opportunity to audit and review the work undertaken by BDSG members to promote the risks of IPO. The members have made an outstanding effort to raise awareness of the risks of IPO and those members who operate internationally, have made it clear, how far ahead the UK is with reference to the rest of the world in raising awareness of the risks. This is something BDSG members are extremely proud of, although it acknowledges there is more work to be done. 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:
• In 2017 at the National Diving Conference, Dr made the first of several presentations to raise awareness among the most influential members of the diving community.
• Every year, the Annual National Diving Incident Report mentions IPO specifically and its possible involvement in diving incidents and fatalities.
• Multiple articles appear in diving magazines and periodicals e.g. Diver, Scuba and X-Ray magazines.
• Frequent references to IPO on social media and websites.
• Engagement with the National Water Safety Forum (NWSF) to raise awareness of IPO as it is not exclusively a sub-aqua issue. Page 4 of9

Regulation 28 report H.M. Senior Coroner for Gloucestershire - BDSG response
• Guidance materials produced by the BDSG members targeting divers and instructors.
• IPO has been raised in safety bulletins issued by the training agencies, trade bodies and other interested parties.
• 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 hungry at depth' to differentiate IPO from other forms of ascent related conditions.
• Webinars and online seminars either specifically on IPO or including IPO. Most of these are still available online for further access.
• Most training agencies have either produced their own or refer to the BDSG materials available online.
• "Return to diving - safely" material has been created and shared by the training agencies and the BDSG which includes an abundance of refresher material and references to IPO as a risk.
• The medical questionnaires have both been updated to included specific reference to IPO.
• IPO is discussed at all levels of training. More emphasis is made where dives are deeper or using either closed circuit equipment or mixed gases.

Regulation 28 report H.M. Senior Coroner for Gloucestershire - BDSG response The Matter of Concern #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?" Report #2: In an "at work" environment there are regulations which govern the type and frequency for medical examinations. This response refers to amateur diving where other arrangements are in place. 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. The UKDMC explain the reasons why there was a change from periodic diving medical examinations to a self-declaration screening tool and the study which was carried out which recommended the change can be found here: UKDMC Medical self-declaration system explanation UKDMC questionnaire: UKDMC Recreational diver medical declaration form BSAC/ScotSAC and SAA use the UKDMC screening tool. IPO is specifically covered at question 15. UHMS questionnaire: UHMS Recreational diving medical screening system (available in 27 languages). Most of the other training organisations, use the medical screening tools listed on the UHMS site. IPO is covered in these tools, particularly in the Diver Medical Participant Questionnaire (page 2, Box A) and in the Cardiovascular Systems section of the Diving Medical Guidance. Previous arrangements: Prior to the introduction of self-assessment questionnaires between 2000-2002, medical examinations were carried out based on these age bands, <40, 40-50 or >50 at 1, 3 or 5 year intervals respectively. The examinations were carried out by GPs using guidance supplied by the relevant medical committee. Why the change from periodic medicals to screening questionnaires: A detailed study, Medical supervision of sport diving in Scotland: reassessing the need for routine medical examinations, was carried out on 3,000 ScotSAC members and published in the British Journal for Sports Medicine in October 2000. The study's conclusion: "Diving is a safe sport requiring medical supervision, but routine clinical examination of all divers is unlikely to detect significant abnormalities relevant to their fitness to dive. A carefully designed questionnaire will allow most relevant conditions to be identified and save unnecessary expense for both divers and doctors."

Regulation 28 report H.M. Senior Coroner for Gloucestershire - BDSG response There was a 3 year follow-up study: The follow-up study was to assess the effect of the new medical system on medical referee workload, diver exclusion rates, and diving incident frequency. Here is the link: Three year follow up of a self certihcation system for the assessment of fitness to dive in Scotland The follow-up studv's conclusion: "In summary, the introduction of a self-administered questionnaire appears effective after three years of follow up, and there has been a reassuring increase in failure rates for divers, confirming the safety of the new screening system. Divers now have the benefit of direct assessment by doctors with diving medicine experience." Other benefits of a self-certification questionnaire:
• Screening for medical abnormalities and changes is carried out much more frequently than would be the case with a periodic medical examination.
• The screening tool can be modified quickly and easily e.g. specific questions are asked about IPO and the screening tools were recently changed to check for the impact of COVID.
• UKDMC list 58 UKDMC Medical Referees, but some only carry out HSE diving medicals and in some parts of the UK there are very few Diving Medical Examiners ("DME") so access is further limited and long distances may be involved e.g. in Scotland, the only two DMEs are both located in the extreme SE of Scotland. The questionnaire removes the need to see a DME except where an abnormality has been highlighted by the questionnaire. There were concerns: The questionnaire is usually completed in isolation by the diver which has raised concerns that some divers may conceal information that is relevant to their fitness to dive. There is guidance within the questionnaires which assists the diver complete the form accurately. A diver who does not answer the questions on the questionnaires accurately, is just as likely to do the same with a DME. It is emphasised that the questionnaires are legal declarations, and if a diver is found to have been fraudulent in its completion, then his/her insurance is not valid. Throughout a divers' training, they are encouraged to take responsibility for their own safety and their diving partner so it is hoped they would recognise the responsibility they have and will answer the questions accurately. 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. UKDMC - What is Immersion Pulmonary Oedema (!PO)

Regulation 28 report H.M . Senior Coroner for Gloucestershire - BDSG response BDSG recommendations:
• The current assessment questionnaires do ask about the diver's history of IPO, but embedded in a more complex question. A recommendation might be that both medical assessment questionnaires ask a simple binary question relating to IPO only e.g. "Have you had IPO (Immersion Pulmonary Oedema) before. YIN?" o UKDMC question 15: "Have you ever had or suffered from: Decompression illness, immersion induced pulmonary oedema or other diver related problem?" o UHMS current question is on page 2, Box A: "I have/have had: a problem or an illness that involved my heart such as: angina, chest pains on exertion, heart failure, immersion pulmonary edema, heart attack or stroke OR am taking any medication for any heart condition."
• 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.
• Chief Constables pass on guidance to Police Officers about how to preserve and gather evidence at a diving incident and which key pieces of information would assist the Pathologist and Coroner in their diagnoses and conclusions.
• There should be a clear reporting pathway between Coroners and BSAC who are the custodians of the National Diving Incident database. The objective being to improve the quality of the information regarding the cause and contributary factors relating to diving fatalities.
• BSAC, the BDSG and/or the Coroner's Service should keep the National Water Safety Forum informed as IPO can affect all water users and is not limited to scuba diving.
• Within the diving community, Dr is recognised as the leading authority on IPO. He has offered to assist Coroners and Pathologists if they feel they would benefit from his expertise in explaining the possible links in diving fatalities to IPO. There are other diving medical experts on the UKDMC and at the DDRC who have offered their assistance in explaining those links too. Summary: The awareness of IPO in the UK is significant greater in the UK compared to the rest of the world. This, in part, is due to considerable efforts made by BDSG and its members in promoting the risk. The BDSG members would very much welcome the assistance of the Coroner's Service and others (as outlined above) to help show the true extent/scale of the problem so that divers not only fully appreciate the risks associated with IPO but take the risks seriously. As outlined above, there is no screening test that can definitively determine whether an individual will suffer from IPO, but there are a number of known factors which increase the likelihood of an individual being subject to IPO. Completing either the Page 8 of9

Regulation 28 report H.M . Senior Coroner for Gloucestershire - BDSG response UHMS or UKDMC medical declaration form prior to any training/diving taking place helps in identifying the known risk factors. Whilst BDSG members fully appreciate the Coroner's concerns, it is not felt that a 'fitness to dive' medical certificate, as a prerequisite to participation in diving activities, is required. A detailed study shows the value of the assessment form in the UK and other studies abroad support the same conclusion of the UHMS questionnaire.

Dear Ms Skerrett, I am replying on behalf of the United Kingdom Diving Medical Committee (UKDMC) to the Matters of Concern raised in your Report to Prevent Further Deaths dated 5 January 2022. Question 1 asks "Whether there is sufficient awareness of the risks & affects of Immersion Pulmonary Oedema (/PO) by those engaged and/or participating in the activity of diving?" Although IPO was first described 40 years ago medical research into the causes, prevention and management is incomplete. As a result, there is incomplete awareness of the risks and effects of this condition amongst doctors (including medical referees for diving and pathologists), Coroners and divers. Members of the UKDMC were the first to report IPO and have worked to promote awareness of the latest information about it in all communities engaged and/or participating in the activity of diving.
• We continue research into IPO and publish our findings in the medical literature to educate doctors throughout the world.
• 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 1 Oyears.
• 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.
• 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)
• We work with the British Diving Safety Group and its sub-committee that has the specific purpose of increasing awareness of IPO
• We have spoken to the Royal College of Pathologists in order to publish an article on diving related diseases, including I PO, 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

IPO and post-mortem decompression artefact but were disappointed that it was not distributed to all Coroners. We will continue with these and similar activities in future. Most divers will, by now, be aware of the symptoms of IPO and that it can be fatal but we note that awareness of serious risks in other activities such as smoking or mountain climbing does not necessarily prevent individuals from participating in them. Question 2 asks "Whether sufficient consideration has been given to the requirement for a 'fitness to dive' medical certificate as a prerequisite to participation in diving activities?" 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. 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. 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 divers who did not declare any problems. Some 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. 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. 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.

Dear Ms Skerrett, Regulation 28 Report to Prevent Future Deaths - Richard Paul Victor Sanders (the "Report") I refer to the above referenced Report which was addressed to (among others) me in my capacity as the Managing Director of the National Diving and Activity Centre ("Diving Centre"). In section 7 of the Report, you have requested that I respond to the third matter of concern identified in paragraph 5 of the Report, namely: "Whether more efficient methods and techniques of diver removal from the water could be employed at the diving centre." 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. Under the new ownership, Deep Training Services Limited ("DTSL"), a company incorporated under the laws of England and Wales, with registered number 13796545, now offers limited access to the quarry for diving activities. DTSL have asked that I confirm to you that they are implementing a requirement that, when any diving activities are being conducted at Dayhouse Quarry, there must be safety boat capability available to assist with the removal of a diver from the water. If you require further information regarding the current operation of dive training activities at Dayhouse Quarry, please contact DTSL directly, at either of the following addresses:
1. Dayhouse Quarry Tidenham Chepstow NP16 7LQ
2. Central Court N.D.A.C. Ltd trading as The National Diving & Activity Centre Registered in England and Wales. Company Reg No: 05439080 VAT No: 862282910

25 Southampton Buildings London WC2A 1AL If you any further questions regarding the operation of the Diving Centre before 23 December 2021, please do not hesitate to contact me. / Many thanks fl~(;lt~ Director NDAC Ltd

--=-----◄-------­ HM Senior Coroner for Gloucestershire the national Ms Katy Skerrett Gloucestershire Coroners Court diving&activity Corinium Avenue centre Barnwood Gloucester The National Diving & Activity Centre Tidenham Quarry GL4 3DJ Tidenham, Chepstow ENGLAND Gloucestershire NP16 7LH

26.02.2022

Email info@ndac.co.uk

Death of Mr Sanders Dear Ms Skerrett, Many thanks for your prevent further deaths where I was directed to respond to point 3 in of number 5 of the report. The requirement for any party conducting a diving operation at the former quarry at NDAC Ltd. The site has now been sold to DEEP/DTS) prior to Christmas who wish for the following information to be passed onto your office. 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 appro riate to do so. Many thanks

Director NDAC Ltd N.D.A.C. Ltd trading as The National Diving & Activity Centre Registered in England and Wales. Company Reg No: 05439080 VAT No: 862282910