The BC inflator was extremely slow, delivering only 30 litres/minute
Thanks for providing some additional information, I did wonder if there was a buoyancy issue when I read about “pulling up the line” on the way to the surface.
In conjunction with the coroners comments we might suppose that negative buoyancy plus work of breathing (gas density & perhaps using a recreational regulator?) along with anxiety/inexperience, and perhaps thermal exposure, contributed to whatever it was that caused her stop stop breathing during the ascent