Here's the response from the coroner:
Dear Counselor Halloran:
Thank you for your further enquiries received on 3 December 2014.
Unfortunately, under the law pertaining to inquests in Jersey, the Deputy Viscount (as coroner) is not in a position to release reports or statements to you. As the inquest has now concluded, he is not able to discuss the evidence further, nor to be addressed on the facts of the case. By law, the purpose of the inquest is to find the answers to four factual questions, being who the deceased was, where, when and how she died. The law specifically prohibits any finding of blame or liability. These matters would be dealt with by separate court action.
However, as mentioned in previous correspondence, the Deputy Viscount has written to various authorities including Hollis UK and the Trading Standards Department Devon and Somerset with the findings of the inquest and the inspection of the equipment by the Health and Safety Laboratory, England. It is hoped that this will stimulate appropriate action to prevent further fatalities of a similar nature.
With very kind regards
Sheila
Sheila Pierce
Corporate Services Officer
Viscount's Department | Morier House | Halkett Place | St Helier | JE1 1DD | Tel: +44(0)1534 441402 | fax: +44(0)1534 441499 | email:
s.pierce@gov.je
From:
dhalloran@halloranlaw.org [mailto:dhalloran@halloranlaw.org]
Sent: 13 December 2014 06:54
To: Sheila Pierce
Subject: Follow up Coroner inquiry
Ms. Pierce,
Will you be responding to my follow up inquiry sent two weeks ago?
Dan Halloran, Esq.
On Dec 2, 2014, at 6:03 AM, Sheila Pierce <S.Pierce@gov.je> wrote:
Counselor Halloran
The Deputy Viscount has asked me to reply as follows:
The rebreather equipment in question was a Hollis Prism 2 Rebreather.
The Deputy Viscount has written to various authorities including the manufacturer and the Trading Standards Department Devon and Somerset. This will outline the findings of the inquest and the inspection of the equipment by the Health and Safety Laboratory, England.
The main findings of the inspection of the equipment were:
It appears the rebreather did not comply with clause 5.1 of BS EN 14143: 2013 or BS EN 14143: 2003.
The rebreather had been put together such that the gas would not circulate in the required loop and CO2 would not be removed from the inhaled gas.
The inhale counter lung was positioned to the divers right hand side, instead of the left hand side.
The exhale counter lung was positioned to the divers left hand side, instead of the right hand side.
The one way inhale valve that should be positioned on the inhale side of the mouthpiece, to ensure the gas circulated the loop, was found butted against the one way exhale valve of the mouthpiece stopping any gas passing into the exhale counter lung on the divers right hand side.
The unit was flooded with fluid.
The cover for the scrubber bucket and head were missing, apart from a small piece attached to the fitting above the battery housing.
Two of the three oxygen sensors were reading 0.18 and 0.16 partial pressure of oxygen (ppO2) when exposed to air (0.21 ppO2), and when put into a 100% oxygen atmosphere (1.00ppO2) gave a reading of 0.80 oxygen. The third indicated 0.00 oxygen in air and 0.28 in 100% oxygen.
Two of the oxygen sensors were labelled Do not use after Nov 2013.
The log book from the dive computer indicated that the diver appears to have stopped moving after 3.00 minutes into the dive.
In addition, from the evidence heard at inquest:
The pre-breather checks carried out on land by Mrs Smith were for 5 minutes (believed to be manufacturers recommended time) and this would have been insufficient time for the build-up of CO2 to be recognised by Mrs Smith. 10 minutes might have been more appropriate.
There are three oxygen sensors on this equipment, but no CO2 sensors. Some form of CO2 sensor might be appropriate.
In UK terms this would be labelled as an accidental death, possibly misadventure, however, inquests in Jersey have narrative verdicts. The verdict in this case for Mrs Jillian Smith (age 41 years and 7 months) was as follows:
That she died in the afternoon of Saturday 15th March 2014 at St Catherines Slipway, St. Martin, [Jersey] after having been found unconscious in the sea during an underwater dive at St Catherines Breakwater; the cause of death was asphyxia caused by obstruction of the airways by inhalation of gastric contents due to unconsciousness by hypercapnia; this occurred after failure of the incorrectly assembled rebreather diving equipment that she was using whilst underwater during her dive.
The inquest was informed that the manufacturer, Hollis, has now modified the mouthpiece assembly and re-issued it.
For your information, the coroner on the Island of Jersey has the title of Deputy Viscount.
Kind regards
Sheila
Sheila Pierce
Corporate Services Officer
Viscount's Department | Morier House | Halkett Place | St Helier | JE1 1DD | Tel: +44(0)1534 441402 | fax: +44(0)1534 441499 | email:
s.pierce@gov.je
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---------- Post added December 15th, 2014 at 03:40 PM ----------
Essentially they will not release lab reports or explain the basis of any conclusions reached. They indicated no one has been charged (manufacturer or instructor) but they did not know if it was a new or used unit. The report could not identify the cause precedent- (ie hypercapnia, oxygen toxicity, hypoxia, etc)- which precipitated the drowning.
So really.... They were no help. Bat least we know where the regurgitated snippets that were posted came from...