I have received a copy of the BC Coroner's report on the death of Cpl. Voisine.
The official record of the incident itself corresponds with witness accounts already posted here. Cpl. Voisine was seen to be significantly exerting himself while donning his drysuit pre-dive, but he did not complain of feeling unwell.
The official cause of death is listed as drowning, with contributing factors including cardiovascular health conditions and hypercapnia (high CO/2 levels in the bloodstream), "due to elevated levels of carbon dioxide in the dive cylinder and excess ballast weight".
An autopsy found no sign of trauma or heart attack, though evidence was found of heart disease and a possible hereditary heart condition.
His gear was examined and found to be in good order, except that his ballast was determined to be in excess of recommended weight (45lbs of ballast and a total gear weight of 104lbs).
Most notably, upon analysis, the air in this cylinder, "was found to contain a level of carbon dioxide (CO/2) at 710.40(ml/ml3) which exceeds the acceptable level of 500(ml/ml3)", it goes on to note that, "Although Mr. Voisine routinely checked and serviced his dive cylinders, the investigation was unable to determine conclusively, where this particular cylinder was replenished with air."
According to his computer, Cpl. Voisine's rate of air consumption on his final dive was nearly double that of previous dives to the same depth.
From these facts, the report concludes that, due in some part to his medical history, coupled with the strain he was under from his exertions at the surface and being overweighted in the water, Cpl. Voisine rapidly consumed air from a tank with an unacceptably high level of CO2, which was itself under pressure and therefore concentrated, until he lost consciousness from hypercapnia and ultimately drowned.
The BC Coroner has classified this as an accident and has made no further recommendations.
PM me if you would like to read the report in full.
