Scuba instructor failed in duty of care during fatal dive16 October 2012
A diving instructor and his diving school failed to request crucial medical information from a student who subsequently died during an excursion off the coast of Dorset.
Bristol Crown Court heard Ian Johnson, an instructor and director of Subaquaholics Ltd, allowed Janek Karon to take part in recreational and training dives on 18 and 19 October 2008, off Portland in Dorset.
Mr Karon did not complete a medical screening form, which would have flagged-up his various conditions that put him at risk of coronary artery disease. This notification would have resulted in him being referred to his GP to assess whether he was fit to dive.
During the second day of diving, he came into trouble as he began to surface. Johnson, an instructor trained under the standards set by the Professional Association of Diving Instructors (PADI), alerted the dive-boat skipper and the two men managed to get Mr Karon into the boat. They attempted to resuscitate Mr Karon, but he did not respond. He was airlifted from the boat and was later pronounced dead in hospital. An inquest found Mr Karon died from drowning, with coronary artery disease a contributing factor.
The HSE investigated the incident and learned Mr Karon had high blood pressure, was clinically obese, had a high cholesterol reading and chronic kidney disease, and had been prescribed statins to reduce his risk of coronary heart disease. He also suffered from Raynaud's syndrome, which is a condition where the vascular system responds to cold by shutting down the circulation in the extremities of the body.
As part of the investigation, the HSE consulted Mr Karon’s GP and an expert diving doctor, who both confirmed that he wouldn’t have been passed fit to dive, owing to his medical conditions.
The HSE also found that Mr Karon was a relatively inexperienced diver, but Johnson’s diving log showed that on the fatal dive the men descended to a depth beyond 30 metres. Under guidelines provided by PADI, a dive between 18 and 30 metres is classified as a deep-water dive, which is only suitable for divers with greater training and experience than Mr Karon.
At the time of the incident, Mr Karon’s 10-year-old daughter, Emma, was also a student with Subaquaholics. During the investigation, the HSE came across a medical form, which stated that Emma suffered from asthma and had a prescription for asthma medication. However, Emma was not referred to a GP before being allowed to dive, even though this is a legal requirement for anyone with this condition.
The HSE identified that the company had failed in its duty of care to both students, and hadn’t carried out a risk assessment or diving project plans. It also failed to ensure that a rescue diver accompanied Johnson during the fatal dive.
Two Prohibition Notices were issued to the company, which ordered it to stop diving until a rescue diver was appointed to join every excursion, and until systems were in place to medically-assess students.
Johnson appeared in court on 15 October and pleaded guilty to two breaches of reg. 10(1) of the Diving at Work Regulations 1997. He was fined £2500 for each offence. Subaquaholics appeared at the same hearing and pleaded guilty to breaching s3(1) of the HSWA 1974. It was fined £10,000. Costs for both parties will be decided at a later hearing.
In mitigation, Johnson said neither he nor his company had any previous convictions and had complied with the enforcement notices. He added that PADI expelled both him and Subaquaholics as members of the Association and, as a result, the company is no longer trading.
After the hearing, HSE inspector Richard Martins said: “Both Ian Johnson and his company fell far below the standard required of those who engage in SCUBA diver training. Mr Karon’s health should have prevented him from diving, and yet he was taken to a depth which only experienced divers should reach. Aside from his health problems, Mr Karon was clinically obese. A specialist in diving medicine and Mr Karon’s own GP were of the same clear opinion that he would not have passed a diving medical.
“Emma Karon was also put at risk by being allowed to dive, given she suffered from asthma but was not assessed by her GP.
“In addition, the risk assessments for the weekend’s diving were entirely inadequate, while most of the documents required by law were missing. These are significant failings, which had fatal consequences for a vulnerable student diver.
Join SHP Online
- ✔ Download free reports and research
- ✔ Access free Digital magazine
- ✔ Email newsletter briefings