38 year old female skipper goes missing off tourist snorkelling boat in the Great Barrier Reef.

Inquest dates: 9 December 2016; 1 February 2017 - 3 February 2017 Coroner: Deputy State Coroner, John Lock Place: Cairns Date of death: 6 April 2016

Issues for Consideration

  • To better understand the circumstances of her death and uncover any information that may not have yet come to light.
  • Whether Leila’s employer took reasonable steps to ensure her safety on the day of the incident.
  • The adequacy and timeliness of the steps taken by individuals, other vessels, police and emergency services to locate Leila once she was missing.
  • The adequacy and timeliness of professional retrieval and emergency medical care available and provided to Leila once she was located.

Case Summary

Leila was a 38 year-old woman working as a skipper on a boat Ocean Free in the Great Barrier Reef near Green Island off Cairns. On 6 April 2016, at 1:30pm whilst swimming to retrieve a dinghy that had come loose, she went missing. She was located in the water some 50minutes later at 2:18pm.

CPR efforts were commenced but she could not be revived. The aeromedical retrieval helicopter was contacted but was unavailable. Leila’s body was taken to the mainland on a water police vessel.

Evidence

Witness evidence

  • When it was realized that Leila was missing a number of vessels in the area were called to help locate her. An official emergency call was made at 2:06pm alerting water police. Leila was located at 2:18pm.
  • CPR efforts were commenced immediately. Chest compressions and O2 were administered and she was taken to Green Island. The persons assisting with CPR were of the impression that Leila was already deceased at that time.
  • Once on Green Island an automatic defibrillator was applied but read ‘no shock’. A Royal Flying Doctor Service’s (RFDS) medical kit was also held on the island and RFDS was contacted and clinical advice was given over the phone.
  • Despite continued efforts Leila showed no signs of life and she was declared deceased at 3:19pm.

Autopsy results

  • There was a severe narrowing of one of the arteries in Leila’s heart. There was no evidence of marine bites or stings and no drugs or alcohol in her system.
  • It was concluded that the cause of death was most likely drowning following cardiac rhythm disturbance.

Queensland Ambulance Service (QAS)

  • When it was discovered that there was no aeromedical resources available it was requested that the Queensland Police Service provide transportation for paramedics.
  • Leila was declared deceased prior to the arrival of paramedics.

Royal Flying Doctor Service (RFDS)

  • Dr Vogler was working as a medical officer for the RFDS and gave permission to use the adrenaline etc in the RFDS medical kit on Green Island.
  • Dr Vogler called Retrieval Services Queensland (RSQ) to ask for assistance.
  • Dr Vogler received a further call at 2:43pm and was advised a paramedic had applied an oxygen mask while CPR was continued. The defibrillator read that it was a non-shockable rhythm so the only treatment for the patient was adrenaline. Dr Vogler advised that 1mg IV adrenaline should be administered approx. every 4 mins and to continue CPR until a plan for retrieval could be made.
  • Dr Vogler spoke again with RSQ and was informed that the helicopter was offline for maintenance. RSQ had arranged for a police boat to be deployed.
  • Dr Vogler discussed the prognosis with the RSQ doctor and it was agreed that a poor outcome was highly likely and it was reasonable to cease CPR.
  • Dr Vogler called Green Island and advised that the lack of response for 60 mins of CPR with adrenaline suggested they were dealing with a futile outcome and that the police boat would not arrive for a further 45mins and prolonging CPR was unlikely to change the outcome. The team agreed to cease CPR.

Queensland Government Air (QGAir)

  • It was not the practice of QGAir to deploy backup aircraft to Cairns if the helicopter was offline for a minor period.

Findings

  • There is no evidence that an earlier emergency call would have made a significant difference to the search activities.
  • The earlier emergency call may have allowed more time for coordination of emergency services. However, given the time taken to locate Leila it probably would not have made any difference.
  • The decision made to make an alternative retrieval plan by way of water police vessel, rather than attempting to identify other aeromedical assets, was reasonable in circumstances where CPR was already underway (and alternative aeromedical assistance was likely to take longer anyway).

Recommendations

  • No specific recommendations were made.
  • It was noted that there was a move by Queensland Health to review the Emergency Helicopter Network and the company owning the Ocean Free decided independently to improve their safety management.

Chronology of Events

6 April 2016
Leila took out the Ocean Free to Green Island with 9 passengers and one other crew member.
After a morning of snorkelling and lunch (on the boat) Leila took seven of the passengers over to Green Island on the dinghy.
1310 Hours Leila noticed that the dinghy had come loose and was approximately 500m away. After a brief discussion with the crewmate Leila decided to swim to a nearby vessel (The Tank) which was anchored approx. 400 – 500m away and use it to retrieve the dinghy.
A crewmate watched Leila swim approximately two-thirds of the way to The Tank. He was confident in her swimming and she showed no signs of distress. He went to the bathroom.
1330 Hours The crewmember returned a few minutes later he could not see Leila. He looked for her with two other tourists for a minute or so and then called an alert on the radio.
1406 Hours An emergency call was made via radio alerting water police and emergency services.
1418 Hours Leila was located by another vessel.
1421 Hours A telephone call was made to RFDS requesting permission to access the medical chest.
A call was made by RFDS to RSQ regarding retrieval.
1443 Hours RFDS called and instructions provided regarding administration of adrenaline and CPR.
A second call was made from RFDS to RSQ and advising that the helicopter was unavailable and water police had been dispatched. Leila’s prognosis was discussed and it was decided it was a futile outcome.
RFDS called Green Island back and advised of retrieval service. Discussed and determined continued CPR should be ceased.
1519 Hours Leila declared deceased.