I've been looking at rebreather accidents for many years, and involved in several investigations. IMO there is little useful to the rebreather diving community at large to be learned from examination of the public record. The focus of law enforcement (in the US) is to determine there was no 'foul play' involved, and once the determination is made it's not murder then the responsibility for digging much deeper is going to pass to someone else. The coroners job (sometimes called a medical examiner in the US) in these circumstances is usually just to name a cause of death.... typically "drowning" but sometimes if the underlying health condition was the obvious cause (for example heart disease that resulted in MI) then the cause of death will be reported as the medical condition. As one coroner told me, "If there is water in the lungs, they drowned." Given the burdens of their jobs, these officials are unlikely to investigate further. A simple, relatively clear, statement of cause is all they need to provide; technical investigation in the cause of rebreather accidents is not their job nor are most of them qualified to do so even if there was incentive.
It's become increasingly difficult to provide expert information to law enforcement and coroners in my experience, in part because they are gun shy of the optics of communicating with the experts. Further, increasingly the experts don't want to be involved either. The reasons are many but the reality is that litigation more often than not will eventually occur because liability insurance payouts may require it. The court cases are, surprisingly to many, not about determining a "cause" but rather apportioning liability to those best able to pay. Thus, I've observed parties on both sides of the same case seeming to obscure facts and discredit evidence. One tactic employed by attorneys is to attack the evidence by discrediting the sources, such as the recovery divers and experts advising law enforcement. In some cases by naming in the lawsuit itself those involved in the collection of the evidence and accusing them of "spoliation of evidence". IMO, looking to official records or filing a lawsuit to learn the cause of a rebreather dive accident is an oxymoron.
When experts look at rebreather accidents, we almost always find long (some times amazingly long) error chains that include almost unbelievable lapses in judgement by the victim and typically by many others as well. But I've never found anything that is going to result in an OMG moment where some press release warning divers of a new here-to-fore unknown cause of rebreather deaths. Like open-circuit diving accidents, the causes of closed-circuit diving accidents are now understood. That's not to minimize the loss of life or the investigation in to the accident, but simply to point out that we already have the knowledge to dramatically reduce rebreather accidents. We simply lack, to some extent, the will to put that knowledge in to action in order to save lives. For example, we know checklists save lives yet there is still a large body of rebreather divers that don't consistently use checklists and even some well respected rebreather divers that argue against the use of checklists.
All of this pales in comparison to the toll these fatal rebreather accidents take... the victim's life of course, but also their family, the recovery divers, the diving experts, and the diving community at large. I have seen first hand the often overlooked toll it takes on the lives and careers of the government officials whose job it is to deal with the aftermath of rebreather fatalities.