Denis Cronin
16 Sept 2016 · Coroner Catherine Mason · Leicester City and South Leicestershire
The coroner's concerns
1. lack of training record
“No training record is kept to evidence when training /practice took place”
2. non compliance with BSAC training
“Training was not in accordance with BSAC Sports Diver training”
3. incorrect DSMB inflation depth
“The plan for the second dive was for Mr [name redacted] to inflate the DSMB from a depth of around 17 metres. It took place at 20 metres. The BSAC instructions for Sports Diver are for the exercise to be conducted at 10 metres”
4. unqualified instructor teaching
“A diver without the necessary qualifications and experience was permitted to teach Mr [name redacted] with no instruction otherwise”
5. absence of risk assessment
“No written risk assessments /templates were completed to ensure those responsible for the dive have focused their minds to relevant circumstances”
6. improper dive planning
“The dive was not properly planned. A Safety and Development Manager employed by BSAC said he would not have done the final dive in the way that it was planned and conducted”