A SCUBA-diving fatality.

An investigation by a Naval Board of Inquiry into the circumstances of a fatal naval diving accident is presented. Although drowning contributed to the fatal outcome, massive arterial gas embolism is thought to have been the principal cause of death, and the value of post-mortem computed tomography scanning for its detection is demonstrated. The possibility is discussed of diver error due to unfamiliarity with equipment and procedures, compounded by nitrogen narcosis. The shortfall in expertise of coronial inquiries into diving deaths is emphasized against a background of increasing popularity of sports diving around Australia. The implications for the offshore industry are obvious and suggest the need for a federal diving inspectorate.