Regulator had deteriorated mouthpiece, examiner tells court
A Coroner’s Jury returned a verdict of misadventure after hearing details surrounding the death of resident diver Pamela Langevin in March 2012.
Witnesses called included Scott Slaybaugh, who is in charge of the diving programme at the Cayman Islands Department of Environment and qualified in diving safety and equipment repair.
Mr. Slaybaugh had been asked to examine the equipment used by Mrs. Langevin when she went with a buddy on a shore dive from behind the Cracked Conch in West Bay.
Mr. Slaybaugh first noted which items were in good condition. He said Mrs. Langevin’s dive computer showed her having been in the water for 34 minutes, to a maximum of 63 feet, in a combination that was generally safe to prevent decompression illness. However, there was a rapid ascent from 30 feet, which was inconsistent with safe diving practice.
The regulator was mechanically functional, although it appeared in need of servicing. The brass filter between the starter and the first stage of the regulator was corroded, indicating a need for maintenance. Inhaling through the second stage required more effort than usual, Mr. Slaybaugh explained, although it was not inherently dangerous for shallow dives.
The most noticeable and significant defect was the mouthpiece, which was badly deteriorated and had a tear more than halfway around the circumference on the bottom. It is possible to breathe through a regulator with a torn mouthpiece, Mr. Slaybaugh said; however, there is risk of inhaling water, which may result in coughing or choking. Ideally, the diver should switch to the back-up regulator.
He indicated that sudden ascent may have been preceded by panic after inhalation of water.
Mrs. Langevin’s dive partner, Judith Steinbock, said they had been returning to shore on a gradual ascent and she was looking around at the scenery. She received no indication from Mrs. Langevin that she wanted to go up, but when she looked again her friend was on the surface, so she went up.
She observed that her friend was using her back-up regulator and was in distress. She was wheezing and her speech was laboured.
Ms Steinbock had difficulty reaching her friend because of the movement of the waves; she observed when her friend stopped swimming. She got to Mrs. Langevin and held her head up, but her friend was unconscious at that stage.
People on shore came and got them out of the water.
Ms Steinbock said she rented her dive equipment, including air tanks for herself and Mrs. Langevin, from the dive company Sun Divers. Mrs. Langevin had her own buoyancy compensator device and regulator, but when she attempted to assemble her equipment and they checked each other’s as dive buddies are supposed to do, there was a hissing noise.
As a result, Mrs. Langevin did not use her own BCD and regulator. She received a BCD and regulator for free from the dive shop attendant. They again assembled the equipment and checked it, but not minutely, just the air flow, which seemed OK.
Shop attendant Steven Sheed said he checked the equipment visually and it looked in good order. If he had seen any problem he would have put it to one side for the shop owner, Frank Ollen Miller, to repair.
He could not say that the dive equipment in court was what he had lent to Mrs. Langevin because each piece was not individually numbered. However, it did have SD on it, so he could say it belonged to Sun Divers.
The jury also heard statements from individuals who helped removed Mrs. Langevin from the water and administer CPR. Taken to hospital in an unresponsive state, she was kept on life support until the next day when a series of tests confirmed she was brain dead.
The autopsy showed that her lungs were heavy, weighing 1,650 grams when the expected weight would be around 850 grams. There were also tears in the bottom of the right lung.
Pathologist Shravana Jyoti said the physical cause of death was anoxic encephalopathy, related to scuba diving. The underlying cause was pulmonary barotrauma due to rapid ascent causing terminal ocean water submersion.
In her instructions to jurors, Queen’s Coroner Eileen Nervik reminded them that their role was to find out how the death was brought about, not to accord blame. “It is not your role to apportion fault,” she emphasised. “This is not a trial, it is an inquiry,” she said again after summarising evidence. “Anything else is for other courts. It has nothing to do with us.”