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October 2014    Download the Entire Issue (PDF) Vol. 29, No. 10   RSS Feed for Undercurrent Issues
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Anatomy of a Dive Death

how coroners figure out why divers met their end

from the October, 2014 issue of Undercurrent   Subscribe Now

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Ken Kurtis led the panel "Why Divers Die" at the Scuba Show in Long Beach earlier this summer, about dive fatalities in Los Angeles County in 2013. Kurtis, owner of the dive shop Reef Seekers in Beverly Hills, is also the scuba consultant to the Los Angeles County Department of Medical Examiner-Coroner, which has had this position since the 1950s (UCLA professor Glenn Egstrom, a dive research pioneer, was the first, and held that spot for 40-odd years). Because coroner reports in Los Angeles County are public record, starting in the mid-2000s, the department gives a public accounting of the fatalities occurring in its jurisdiction. In this article, Kurtis describes how the department handles investigations and uses evidence and deduction to come up with rulings, then provides a sample of cases it handled last year.

In Los Angeles County, all dive deaths are initially treated as a possible homicide, so one of the Sherriff's first tasks is to make a determination in that regard. The responding sheriff takes control of all dive gear, takes witness statements, may test the gear or turn it over to the Medical Examiner-Coroner, and then transports the body to the ME-Corner's facility. Coroner investigators will conduct their own interviews and receive copies of reports from the various first responders, while Coroner physicians perform an autopsy that includes toxicology screening. The ME-Coroner's goal is to determine the cause of death within reasonable medical certainty. You could have two people look at the same autopsy and test results and come up with two different opinions, so it's important to remember that what the Coroner is producing is an informed medical opinion, based on the evidence available at the time. Its conclusion is not an assessment of legal responsibility.

From a diving standpoint, a Coroner's finding does not always tell us much. While "drowning" may indeed be the medical reason for the death, it is a sometimes unsatisfying conclusion to divers looking for answers. Divers Alert Network (DAN) has come up with a four-step process that involves:

1) Trigger -- what got everything started;
2) Disabling event -- what the trigger caused to happen;
3) Disabling injury -- produced by the disabling event; and
4) Cause of death....

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