Cause of Death: A Deteriorated Mouthpiece?

Diver safety improves when we can learn the specific causes of accidents and deaths. Those don't get publicized in the U.S., but in other countries, especially those using the English system of law, do report on causes and, as you'll see in this case, are very helpful in preventing future mishaps. More specifically, traveling divers are more frequently renting equipment abroad, and while reputable resorts provide well kept gear, problems can happen. In this case, the most unsuspecting piece of gear -- a regulator mouthpiece -- was the culprit.

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A coroner's jury in the Cayman Islands returned a verdict of "misadventure" after hearing details surrounding the death of local diver Pamela Langevin in March 2012. Scott Slaybaugh, who is in charge of the diving program at the Cayman Islands Department of Environment, and qualified in diving safety and equipment repair, had been asked to examined the equipment used by Langevin when she went with a buddy on a shore dive from behind the Cracked Conch in West Bay. 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. Inhaling through the second stage required more effort than usual, Slaybaugh explained, although it was not inherently dangerous for shallow dives.

The most 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, Slaybaugh said but 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.

Judith Steinbock, Langevin's dive partner, said they had been returning to shore on a gradual ascent. She received no indication from 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 Langevin was using her backup regulator and was in distress. She was wheezing and her speech was laboured. Steinbock had difficulty reaching her because of the waves. She got to Langevin and held her head up, but her friend was unconscious at that stage. 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.

Steinbock said she rented her dive equipment, including air tanks for herself and Langevin, from the dive company Sun Divers. Langevin had her own BCD and regulator, but when she attempted to assemble her equipment and they checked each other's gear, there was a hissing noise. As a result, Langevin 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.

Sun Divers 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 owner, Frank Ollen Miller, to repair. He could not say that the dive equipment in court was what he had lent to Langevin because each piece was not individually numbered. However, it did have SD on it, so he could say it belonged to Sun Divers.

Pathologist Shravana Jyoti said the physical cause of death was anoxic encephalopathy, related to diving. The underlying cause was pulmonary barotrauma due to rapid ascent, causing terminal ocean water submersion.

- - Carol Winkler, Cay Compass