Recurance · prevention of future deaths reports
Pre-inquest brief
Insufficient awareness of immersion pulmonary oedema risk for high bloodpressure
The earlier warning
Richard Sanders · 5 Jan 2022 · Katy Skerrett, Gloucestershire
“Whether there is sufficient awareness of the risks & affects of immersion pulmonary oedema by those engaged &/ or participating in the activity of diving.”
judiciary.uk/…/richard-sanders-prevention-of-future-deaths-repo…
What was promised
Stated action 1 · response to Richard Sanders (5 Jan 2022) · stated timescale: none stated
“The BDSG has created, and is continuing to compile a pack for use at an incident to help preserve evidence: BDSG Serious Accident Guide for Divers v1.”
judiciary.uk/…/2022-0003-Response-from-British-Diving-Safety-Gr…
Stated action 2 · response to Richard Sanders (5 Jan 2022) · stated timescale: none stated
“We will continue with these and similar activities in future.”
judiciary.uk/…/2022-0003-Response-from-St-Richards-Hospital_Pub…
What recurred
- 30 Apr 2026 · Kevin Lapwood · Heidi Connor · Identical hazard · confidence 0.92 (high)
The clearest link, quoted from both reports:
Earlier · Richard Sanders · 5 Jan 2022
“Whether there is sufficient awareness of the risks & affects of immersion pulmonary oedema by those engaged &/ or participating in the activity of diving.”
Later · Kevin Lapwood · 30 Apr 2026
“I am concerned about the level of training and awareness around the risks of immersion pulmonary oedema('IPO') for divers with high blood pressure.”
What happened next
No web check of the stated actions has been published for this chain.