Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0588, written 18 Nov 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Nov 2025 |
|---|---|
| Reference | 2025-0588 |
| Deceased | Dominic Hurley |
| Coroner | Penelope Schofield |
| Coroner area | West Sussex, Brighton and Hove |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1. British Sub Aqua Association Telfords Quay, South Pier Road, Ellesmere Port, Cheshire, CH65 4FL 2. Sub Aqua Association Space Solutions Business Centre, Sefton Lane, Maghull, Liverpool, L31 8BX. 1 CORONER I am Penelope SCHOFIELD, Senior Coroner for the coroner area of West Sussex, Brighton and Hove 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 12 July 2024 I commenced an investigation into the death of Dominic Edward Arthur HURLEY aged 57. The investigation concluded at the end of the inquest on 21 October 2025. The conclusion of the inquest was that: On 8 July 2024 Dominic Hurley was undertaking a dive offshore on the HMS BROMPTON. Towards the end of the dive he became unwell and this led to a rapid uncontrolled ascent. On reaching the surface he was recovered to the diving boat but became unconscious shortly thereafter. CPR was commenced. An air ambulance took him to the Royal Sussex County Hospital in Brighton for treatment. Sadly he did not recover and he sadly died later that day. 4 CIRCUMSTANCES OF THE DEATH On 8 July 2024 Dominic Hurley was undertaking a dive offshore on the HMS BROMPTON. Towards the end of the dive he became unwell and this led to a rapid uncontrolled ascent. On reaching the surface he was recovered to the diving boat but became unconscious shortly thereafter. CPR was commenced. An air ambulance took him to the Royal County Sussex Hospital in Brighton for treatment. Sadly he did not recover and he sadly died later that day. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) In 2018 Mr Hurley suffered shortness of breath and pulmonary oedema during a dive in Malta. This led to him having a heart bypass on his return to the UK. There was significant family history of cardiac related issues. Time passed but in 2021 and 2023 Mr Hurley sort to renew his diving licence. Mr Hurley completed his self declaration questionnaire. At no stage did he declare the events in 2018 in relation to his dive and nor did he discuss this with the Dr assessing him. It is likely that had the Dr been aware of the previous diving incident a different course of action may have taken. There is currently too much reliance placed on the self declaration questionnaire without any further enquiry or access to previous medical history. This leads to a false Regulation 28 – After Inquest Template Updated 15/07/2025 TG sense of reality and put the diver and others at potential risk of death on further dives. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by January 12, 2026. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons The family of Dominic Hurley Hyperdive Health and Safety Executive (Diving division) Professional Association of Diving Instructors (PADI) who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. They may send a copy of this report to any person who they believe may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Dated: 18/11/2025 Penelope SCHOFIELD Senior Coroner for West Sussex, Brighton and Hove Regulation 28 – After Inquest Template Updated 15/07/2025 TG
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
The Sub Aqua Association, Space Solutions Business Centre Sefton Lane Maghull, Liverpool L31 8BX Miss Penelope Schofield , Senior Coroner for West Sussex, Brighton and Hove, Parkside Chart Way, Horsham, RH12 1XH. 7th December 2025 Inquest into the death of Dominic Edward Arthur Hurley Regulation 28: REPORT TO PREVENT FUTURE DEATHS Dear Miss Schofield, Thank you for your letter of 18th November 2025 together with the Regulation 28 report and for the copies of Mr Hurley’s complete medical screening forms. My reading of the information provided would suggest that the Immersion Pulmonary Oedema (IPO) was linked to the cause of death and that failure to identify that he had previously suffered an IPO is the concern you are seeking to address. I note from Mr Hurley’s medical questionnaires that IPO was not specifically listed as a condition requiring to be notified. The SAA use the medical screening system managed by the UKDMC (United Kingdom Diving Medical Committee) (https://www.ukdmc.org/). I have checked my medical form archive and note that “immersion induced pulmonary oedema” was introduced in the May 2020 version of the declaration at question 17. The current version, May 2024, of the form has this at question 16. The SAA require our members to complete the diving self-declaration form as follows: 1. On commencement of SCUBA diver training, 2. At the annual membership renewal, renewals due on the 1st March 2021 would be the first time the updated forms was used. 3. Prior to attending an SAA national course, which involves scuba diving 4. On change of their personal medical conditions. Whilst the SAA have adopted the UKDMS system members are also likely to complete a medical screening form managed by the Undersea and Hyperbaric Medical Society (UHMS Medical Screening Forms) when diving on holiday. I have looked at the latest version of their form and this also includes “Immersion Pulmonary Edema” (American spelling). The SAA have no direct involvement with this screen service. I believe that the revision to the current dive medical screening forms now meet the change you are now seeking to make. IPO in diving was discussed at length by the BDSG in 2019. The response to the feedback the SAA have incorporated the identification and treatment of IPO in: • The initial training, the SAA One Star Diving syllabus and in the training manual for that course, • The second level of training, the SAA Two Star Diving syllabus and in the training manual for that course, • The SAA Oxygen Administration and Emergency Diver First Aid course. Whilst the three changes already implemented in the SAA training programme reference will also be included in other syllabuses as they are reviewed. The SAA have included articles about IPO in two newsletters to SAA membership: • July 2017 – The SAA Decompression Officer, flagged the issue with the membership and referenced an updated SAA Elementary Diver lecture to include this. The SAA Elementary Diver grade has since been replaced by the SAA One Star Diver grade. • February 2019 – the NDO provided feedback from the January 2019 BDSG meeting. This covered prevention, identification and treatment. I believe that the SAA has advised its membership and revised their training programme in such a manner as to have already implemented the changes required to mitigate the risk of IPO when diving, in so far as any risk can be mitigated. However, the SAA will ensure that the membership is reminded of the importance of accurately completing medical by emphaising the fact at renewal and with periodic reminders in their newsletter. I am more than happy to provide copies of any of the documents I have mentioned if you would like to see them. I have copied this response to: • • • Yours sincerely, (UKDMC Medical Referee) – SAA Medical Advisor, – Chair of the BDSG (British Diver Safety Group). – BSAC Safety and Development Manager SAA National Diving Officer
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