Experienced diver died after bolting to surface of lake

The student, Richard Sanders, 52, of Bradwell, near Great Yarmouth, was an experienced diver and was training for an expedition off the Orkneys when he died on April 11, 2019 at the National Diving Centre in Tidenham, Gloucestershire.

He was being trained in using a different gas composition in his tanks when he got into difficulties and attempted to surface too quickly as his instructor Mark Culwick fought to slow him down, the inquest into Mr Sanders' death was told.

At the end of the two day inquest at Gloucestershire Coroner's Court the jury returned a conclusion of accidental death.

The National Diving Centre in Tidenham, Gloucestershire. (Image: Google Maps)

Gloucestershire Coroner Katie Skerrett said, however, that she would be considering making a PFD (Prevention of Future Deaths) report to address three issues arising from the tragedy.

She said the issues which concerned her were: whether there is enough awareness surrounding the condition of immersion pulmonary oedema which caused Mr Sanders' death; whether there should be a fitness to dive medical certificate for people in his position, and whether there might be a faster way to get people out of the water in such emergencies.

In the final stages of the inquest, the coroner told the jury “Mr Sanders was a student on a two day trimex course that began on April 10th 2019 with one instructor.

“He was experienced, having completed over 200 dives to a maximum depth of 40 metres.

“A medical questionnaire given to Mr Sanders was completed before diving. Had he answered 'Yes' to any of the questions he would not have been able to dive.

“However, this inquest has heard that Mr Sanders answered 'No' to a number of questions when, more accurately, some of these answers should have been 'Yes.'

“When asked if there was a history of drug or alcohol abuse, a history of blackouts or fainting of if he suffered from back problems he said 'No.' But if he had said 'Yes', further medical assessment would have been required and the dive would not have gone ahead.

“On the first dive on day one Mr Sanders was said to be 'all over the place.' His head was down and the instructor (Mark Culwick) terminated the dive. Mr Sanders was then critical of his own performance.

“A second dive took place later that afternoon and Mr Sanders had regained his confidence and looked comfortable in what he was doing.

“A second student joined the team on the next day and he and Mr Sanders completed a full skills circuit, which included taking off a mask and simulating a decompression ascent.

“Their second dive commenced later in the day at 3.59pm and it was expected to last for 28 minutes.

“Richard was the dive leader and the instructor noticed that he had begun looking at his gauges, which he didn’t need to do, some 20 minutes into the dive.

“The instructor decided to bring the dive to a premature end and gave the appropriate signal. Mr Sanders turned to the other student, who had already deployed his marker buoy, and deployed his own marker buoy with textbook efficiency.

“Mr Sanders then had to disconnect a hose to fill the surface marker buoy, but he didn’t reconnect the hose.

“The instructor moved in closer because he wanted Mr Sanders to reconnect the hose before they began their ascent. It was at this point Mr Sanders gave his instructor a signal that he was out of air.

"But the instructor could see on his gauges that he did have air - his cylinder was still approximately half full.

“The instructor gave him his spare long hose regulator, which caused lots of bubbles, and he soon realised that they were in desperate trouble. This is when Richard bolted, ascending to the surface and taking his instructor with him.

“The other dive student said he saw something going on between Mr Sanders and the instructor but they then disappeared from view.

“The instructor said that the alarms on his wrist were telling him they were ascending too fast: the average rate for complete safety is six metres a minute.

“Mr Sanders was doing his best to rise to the surface while the instructor grabbed his belt to try to slow him down.

“The instructor has told this hearing ‘It was a fight for survival - he was trying to pull me up, I was trying to pull him down’.

“At 23 metres Mr Sanders bolted again. The instructor was terrified as the lines became entangled. It is at this point that the instructor believes Richard became unconscious and just passed away.

“The other student rejoined his instructor and saw that Mr Sanders appeared lifeless.

"The instructor changed his wrist computer to allow him to resurface in the quickest time possible.

“He was on the surface at 4.37pm and swam with Mr Sanders some distance to the nearby pontoon. It would have been a physically demanding distance to swim with a full kit on.

“Nobody was on the pontoon to raise the alarm. He clipped Mr Sanders to a ladder before raising the alarm at 4.40pm.

“When the alarm was raised two people from the offices attended with a defibrillator and oxygen, having already called the emergency services at 4.46pm.

“They proceeded with chest compressions until the ambulance paramedics arrived at 4.56pm. He was declared deceased at 5.18pm.”

The inquest heard that Mr Sanders had been unconscious for eight minutes underwater - three minutes while being towed to the pontoon and a further six minutes before CPR could be commenced.

“Medical experts concluded that if there had been surface cover on the pontoon these timings would have been reduced by three minutes, but in all likelihood this would not have had any effect on the unsuccessful outcome over the resuscitation of Mr Sanders," the coroner said.

The inquest was told that the medical cause of Mr Sanders' death was immersion pulmonary oedema.

A medical expert told the inquest that a diver suffering from this condition would become breathless and think there was a problem with their gas supply and check their gauges, followed by coughing and disorientation. The symptoms get worse as they become vertical and start ascending.

John MacLachlan, from Scuba Quest, the company which held the training course, said that the type of questionnaire form filled in by Mr Sanders at the diving centre now has to be completed earlier, at the time of booking, and that any queries would mean any potential diver has time to resolve any issues before arriving on site.

A friend and fellow diver of Mr Sanders, Steve Smith, told the inquest he wanted the jury to know more about the deceased as a person and went on “I first met him in 2016 and immediately liked him. He was always up for a bit of banter, but he was always a conscientious person, especially when it came to his diving.

“As an alternative to attending a dive that had been cancelled we went to Somerset instead. At the time he was a relatively new diver while the rest of the group were more experienced. He loved diving with us, he was like a sponge. He had a thirst of knowledge for the activity.

“It was a privilege seeing somebody relatively inexperienced come on leaps and bounds.

“This was because of Richard’s commitment and determination to become the best diver he could.

“As his experience grew he became interested in different diving configurations and he also became interested in the technical side of diving too, by reading and learning as much as he could.

“And once he was ready he enrolled in the required courses to progress with his training.

“This was one thing he was strict about was his training and as importantly, his safety.

“He would always make a thorough check of his kit before diving and carry out a full safety check once in the water. If there was any safety concerns Mr Sanders would call the dive off.

“Myself and Richard became interested in the technical side of diving, especially the use of trimex, a gas made up of oxygen, nitrogen and helium, which makes deeper diving safer as it makes your thought process much clearer.

“We had planned to dive the wrecks of the German high seas fleet off the Orkney Islands at depths of 40 metres.

“We had hoped to be part of an expedition to commemorate the 100th anniversary of the scuttling of the ships. This is a dream come true for any serious diver.

“Mr Sanders had made a decision to enrol on a technical trimex course in preparation for this expedition. It would have meant that we would have been able to safely react to any problems encountered during the dives.

“In my opinion Mr Sanders was a very safe, experienced and meticulous diver and had I not felt this way I would have not have been willing to have Richard as my dive buddy on such serious dives.

“He is a very much missed friend and diver. RIP mate.”