Editor’s Note (Updated July 8, 2026): Following publication of this article, Wraysbury Dive Centre contacted The Scuba News to clarify that while the incident occurred at its site, the diving activity was organised and conducted independently by the London School of Diving. Wraysbury Dive Centre acted solely as the venue and was not responsible for organising or supervising the dive. During the inquest, the coroner commended the dive centre’s response to the emergency. We have updated this article to make that distinction clearer while preserving the substance of the coroner’s findings.
A UK coroner has raised concerns about diver training, medical requirements and industry guidance following the death of a volunteer safety diver, warning that similar fatalities could occur unless action is taken.
The concerns are set out in an official Regulation 28 Prevention of Future Deaths (PFD) report issued by Berkshire Senior Coroner Heidi Connor after the inquest into the death of Kevin John Lapwood, who died following a diving project conducted by the London School of Diving at Wraysbury Dive Centre in February 2022.
Although the incident took place at Wraysbury Dive Centre, the dive centre was the venue for the activity rather than the organisation responsible for conducting the diving operation.
Lapwood, 63, was acting as a volunteer safety diver during a London School of Diving project on 12 February 2022. The inquest heard that the lead instructor was working in a paid capacity, while Lapwood was volunteering in a safety role.
Evidence presented during the inquest showed that Lapwood had failed a Health and Safety Executive (HSE) diving medical in October 2021 after being found to have significantly elevated blood pressure and a body mass index above the permitted threshold. Although he informed the diving organisation that he had failed the medical, he did not undergo a further HSE diving medical before taking part in the project.
Shortly after entering the water, Lapwood encountered difficulties. Staff at Wraysbury Dive Centre responded immediately to the emergency and carried out rescue efforts before he was transported to Wexham Park Hospital, where he died the following day.
The coroner concluded that Lapwood died from immersion pulmonary oedema (IPO), with hypertension and coronary artery disease identified as contributing factors. The inquest returned a conclusion of misadventure.
Wider Industry Concerns
Rather than focusing solely on the circumstances of one fatality, the coroner concluded that broader issues affecting the UK diving community warranted national attention.
The Prevention of Future Deaths report was sent to both the Health and Safety Executive (HSE) and the British Diving Safety Group (BDSG), identifying several areas where improvements could help prevent similar incidents in the future.
Among the concerns highlighted were:
- Awareness of medical requirements for volunteers participating in diving projects.
- Understanding of the relationship between hypertension and immersion pulmonary oedema (IPO).
- Whether guidance for shore support and surface cover adequately defines their responsibilities, including maintaining continuous visual observation of divers.
- Potential confusion over when the Diving at Work Regulations apply to volunteer divers participating in organised projects.
- Whether doctors conducting HSE diver medicals should routinely advise divers who fail their medical of the increased risks associated with immersion pulmonary oedema.
Clarifying the Rules Around Volunteer Diving
A significant part of the coroner’s report centres on the potential for misunderstanding within existing guidance.
The coroner questioned whether the title and wording of the HSE’s Approved Code of Practice for recreational diving projects could lead volunteer divers or organisers to believe that certain legal requirements apply only to paid professionals.
Although the guidance does address volunteers, the report suggests it could be clearer in explaining when the Diving at Work Regulations apply to organised diving projects involving volunteer personnel.
Raising Awareness of Immersion Pulmonary Oedema
The report also highlights immersion pulmonary oedema (IPO), a potentially life-threatening condition in which fluid accumulates in the lungs during or shortly after immersion.
While many divers recognise uncontrolled hypertension as a risk factor for heart attack or stroke, the coroner expressed concern that awareness of its association with IPO appears to be much lower.
Increasing awareness of IPO among divers, instructors, dive organisers and medical professionals was identified as an important opportunity to improve diver safety.
Organisations Asked to Respond
Under Regulation 28 of the Coroners and Justice Act, organisations receiving a Prevention of Future Deaths report must respond to the coroner outlining any action they have taken, or intend to take, in response to the concerns raised.
The report was addressed to the Health and Safety Executive and the British Diving Safety Group, with copies also provided to interested parties including the London School of Diving, Wraysbury Dive Centre and PADI.
While a Prevention of Future Deaths report does not determine legal liability or assign blame, it highlights matters where a coroner believes action could reduce the likelihood of similar deaths occurring in the future.
In this case, the report’s recommendations are directed towards improving national guidance, medical awareness and industry practices rather than attributing responsibility to the venue where the incident took place.
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