Source · Prevention of Future Deaths
Kevin Lapwood
Ref: 2026-0238
Date: 30 Apr 2026
Coroner: Heidi Connor
Area: Berkshire
Responses identified: 0 / 2
View PDF
Concerns were raised about insufficient training for volunteer divers regarding medical requirements and immersion pulmonary oedema risks. There is also a lack of clarity in HSE diving regulations and guidance regarding the applicability to volunteers.
Date
30 Apr 2026
56-day deadline
20 Aug 2026 est.
Responses identified
0 of 2
Coroner's concerns
Concerns were raised about insufficient training for volunteer divers regarding medical requirements and immersion pulmonary oedema risks. There is also a lack of clarity in HSE diving regulations and guidance regarding the applicability to volunteers.
View full coroner's concerns
For the avoidance of doubt, each organisation to which this report is addressed is only required to deal with the issues relevant to their own organisation, listed below.
In relation to British Diving Safety Group:
1. I am concerned about the level of training and awareness nationally – specifically of the medical requirements for volunteers involved in projects like Kevin was.
2. I am concerned about the level of training and awareness around the risks of immersion pulmonary oedema(‘IPO’) for divers with high blood pressure. Whilst the more common risks of hypertension will be better understood (such as heart attack and stroke), awareness of IPO appears to be less well understood.
3. I am concerned about whether there is sufficient guidance regarding what the role of shore support /surface cover entails. Specifically, should that include having eyes on the water?
In relation to the Health and Safety Executive:
1. Clarity of the approved code of practice (‘ACOP’) entitled “Recreational diving projects – Diving at Work Regulations 1997”, published in 2014, in the following respects:
a. The title of the document – does this document adequately reflect that it also covers volunteers? Is there a risk that, on reading the initial heading of the document, it may be felt that it is not relevant to volunteers working in the capacity that Kevin did?
b. Would the reference to “associated guidance” on the title page be better with the use of a hyperlink to guidance such as the volunteer diver guidance note?
c. The definition of “diver” in the ACOP is “a person at work who dives”. The definition of “at work” is (in summary) an employee or a self-employed person. Although the guidance does go on to deal separately with those in a diving role as part of a project, there is some potential ambiguity here. For instance, it may be possible to look at the guidance on Regulation 12 which states that no “diver” shall dive in a diving project unless he has an HSE medical. If “diver” is defined as being somebody at work, then there is a risk that the regulations could be interpreted in the way it appears they were here –ie only applying to somebody who is paid. A careful reading of the guidance should make the position clearer, but I believe there is a remaining risk of misinterpretation without very careful analysis of this document.
2. All the titles of the relevant legislation and guidance refer to diving “at work”. It is easily foreseeable that someone looking at this may assume that is not relevant for volunteers used as part of a diving project. I appreciate that naming legislation is not within the gift of the HSE, but it may be something that could be communicated in relation to future legislation, and taken into account in HSE guidance – particularly the titles of any future guidance.
3. I am concerned that there is currently no requirement for doctors conducting HSE medicals to confirm that they have advised patients who fail the HSE medical, for reasons similar to those in Kevin’s case, of the risks of IPO.
In relation to British Diving Safety Group:
1. I am concerned about the level of training and awareness nationally – specifically of the medical requirements for volunteers involved in projects like Kevin was.
2. I am concerned about the level of training and awareness around the risks of immersion pulmonary oedema(‘IPO’) for divers with high blood pressure. Whilst the more common risks of hypertension will be better understood (such as heart attack and stroke), awareness of IPO appears to be less well understood.
3. I am concerned about whether there is sufficient guidance regarding what the role of shore support /surface cover entails. Specifically, should that include having eyes on the water?
In relation to the Health and Safety Executive:
1. Clarity of the approved code of practice (‘ACOP’) entitled “Recreational diving projects – Diving at Work Regulations 1997”, published in 2014, in the following respects:
a. The title of the document – does this document adequately reflect that it also covers volunteers? Is there a risk that, on reading the initial heading of the document, it may be felt that it is not relevant to volunteers working in the capacity that Kevin did?
b. Would the reference to “associated guidance” on the title page be better with the use of a hyperlink to guidance such as the volunteer diver guidance note?
c. The definition of “diver” in the ACOP is “a person at work who dives”. The definition of “at work” is (in summary) an employee or a self-employed person. Although the guidance does go on to deal separately with those in a diving role as part of a project, there is some potential ambiguity here. For instance, it may be possible to look at the guidance on Regulation 12 which states that no “diver” shall dive in a diving project unless he has an HSE medical. If “diver” is defined as being somebody at work, then there is a risk that the regulations could be interpreted in the way it appears they were here –ie only applying to somebody who is paid. A careful reading of the guidance should make the position clearer, but I believe there is a remaining risk of misinterpretation without very careful analysis of this document.
2. All the titles of the relevant legislation and guidance refer to diving “at work”. It is easily foreseeable that someone looking at this may assume that is not relevant for volunteers used as part of a diving project. I appreciate that naming legislation is not within the gift of the HSE, but it may be something that could be communicated in relation to future legislation, and taken into account in HSE guidance – particularly the titles of any future guidance.
3. I am concerned that there is currently no requirement for doctors conducting HSE medicals to confirm that they have advised patients who fail the HSE medical, for reasons similar to those in Kevin’s case, of the risks of IPO.
Report sections
Investigation and inquest
The family requested me to refer to the deceased as Kevin. I will reflect that in this report.
I conducted an inquest into the death of Kevin John Lapwood which concluded on 16th of April 2026. I concluded the following: Kevin Lapwood (aged 63) was acting as a volunteer safety diver for London School of Diving, at Wraysbury Dive Centre, on 12th of February 2022. He was part of a diving project in which the lead instructor was paid. He had failed an HSE medical [shorthand we used for a certificate issued by an Approved Medical Examiner of Divers, as required under the Diving at Work Regulations 1997] in October 2021, and did not have any medical examination for diving purposes after that point. It is likely that immersion (particularly in very cold water) played a part in causing his death.
I reached a conclusion of misadventure.
I conducted an inquest into the death of Kevin John Lapwood which concluded on 16th of April 2026. I concluded the following: Kevin Lapwood (aged 63) was acting as a volunteer safety diver for London School of Diving, at Wraysbury Dive Centre, on 12th of February 2022. He was part of a diving project in which the lead instructor was paid. He had failed an HSE medical [shorthand we used for a certificate issued by an Approved Medical Examiner of Divers, as required under the Diving at Work Regulations 1997] in October 2021, and did not have any medical examination for diving purposes after that point. It is likely that immersion (particularly in very cold water) played a part in causing his death.
I reached a conclusion of misadventure.
Circumstances of the death
On 20th of September 2021, Kevin completed a diver medical participant questionnaire. He replied “no” to all questions apart from being over 45 years of age. He saw his GP, Dr S, on 28th of September 2021. Dr S ticked the box which said Kevin had suffered with disease of the heart and circulation (e.g. high blood pressure, angina, heart attack, chest pains, or palpitations).
On 4 Oct 2021, he saw Doctor F, a doctor with diving experience who was conducting his examination for the purposes of an HSE medical. Kevin failed that test. He had very high blood pressure and was not on medication for it. His BMI was also too high.
Kevin advised AF at the London School of diving that he had failed the HSE medical. Mr T, the manager, advised that he should get sign off from his GP. This exchange of messages took place in October 2021. It appears that Kevin did not have any other medical examination or sign off after that time.
It was arranged that Kevin would act as the safety diver on the second dive at Wraysbury Dive Centre on 12 February 2022. The lead instructor was DK. He was acting in a paid capacity.
Kevin got into difficulty soon after entering the very cold water that day. Despite efficient rescue and resuscitation efforts, he died at Wexham Park Hospital the next day.
I found his cause of death was: 1a Immersion pulmonary oedema 1b Hypertension 2 Coronary artery disease
On 4 Oct 2021, he saw Doctor F, a doctor with diving experience who was conducting his examination for the purposes of an HSE medical. Kevin failed that test. He had very high blood pressure and was not on medication for it. His BMI was also too high.
Kevin advised AF at the London School of diving that he had failed the HSE medical. Mr T, the manager, advised that he should get sign off from his GP. This exchange of messages took place in October 2021. It appears that Kevin did not have any other medical examination or sign off after that time.
It was arranged that Kevin would act as the safety diver on the second dive at Wraysbury Dive Centre on 12 February 2022. The lead instructor was DK. He was acting in a paid capacity.
Kevin got into difficulty soon after entering the very cold water that day. Despite efficient rescue and resuscitation efforts, he died at Wexham Park Hospital the next day.
I found his cause of death was: 1a Immersion pulmonary oedema 1b Hypertension 2 Coronary artery disease
Copies sent to
recipients who have an interest in this matter2. Wraysbury Dive Centre3. Professional Association of Diving Instructors
Similar PFD reports
Related inquiry recommendations
Manchester Arena Inquiry
Review CCTV monitoring SIA licence requirements
Manchester Arena Inquiry
Enact Protect Duty into law
Manchester Arena Inquiry
Establish standard for event healthcare services
Manchester Arena Inquiry
Mandatory Ambulance Liaison Officer at events
Manchester Arena Inquiry
Employer requirement to train in first aid
Manchester Arena Inquiry
Review licensing for security contractors
Report details
- Reference
- 2026-0238
- Date of report
- 30 April 2026
- Coroner
- Heidi Connor
- Coroner area
- Berkshire
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 20 Aug 2026 (estimated).
Sent to
- British Diving Safety Group
- Health and Safety Executive