The Coroner has released his findings in relation to this matter. I cannot locate the full reasons as yet but there is a reasonable summary at this link...
Coroner releases findings into British tourist's scuba death
The Coroner's recommendations are:
- A maximum introductory diver to instructor ratio of 2-1, or 1-1 if conditions are poor (such as current, visibility or surface chop).
- That the term 'resort dive' be renamed to 'introductory dive'.
- That instructors are to be always within arms-length of introductory divers, and to link arms if conditions are assessed as poor or very poor.
- Dive instructors must do a dive site assessment, including assessing visibility with a secchi disk and conducting an in-water (at depth) visual inspection for horizontal visibility and to assess current.
- That elementary dive skills, including mask clearing, regulator clearing, regulator recovery, buddy breathing, Buoyancy Control Device (BCD) inflate/deflate and emergency weight belt dropping are taught until competently demonstrated, within a controlled environment such as a swimming pool.
- That diving groups are staggered and that routes are determined in a way to avoid dive group interaction while underwater.
- That dive instructors have the final decision on whether a dive proceeds or is terminated. Not the tour operator or skipper, who may have commercial considerations influencing their judgment.
- That safety measures include the 'surface watch' personnel having an emergency 'grab bag' on-board, which includes a weighted lost diver marker, and that instructors carry a suitable underwater marker system.
- That swimming fins, if used, must include an accompanying 'fin safe' style retainer strap.
- Whether a policy should be implemented that if any diver becomes separated all divers in a group must immediately surface and inflate their BCD, even though it is an emergency ascent.
- That the Office of Industrial Relations consider, within six months, whether the relevant Code of Practice needs to be mandated as the minimum standard for operations, rather than being "guidelines”.
- That the Dive and Snorkelling Death Review Panel be reformed by the Office of Industrial Relations, preferably within three months.
Personally, as someone who was an
awful DSD student I think there is a lot to be said for lower ratios. I was very fortunate as I was in a one on one situation. Knowing how terrible I was at the start I can see how accidents like this can occur.
Some of the recommendations though I think would be very hard to implement. For example determining routes to avoid dive group interaction underwater.