“Awareness of Immersion Pulmonary Oedema in the medical profession: i.) Concerns were…”
Dated 29 Mar 2023, from the coroner for Surrey. Sent to 4 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 24 May 2023. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated29 Mar 2023
- Deadline24 May 2023
- Published on judiciary.uk31 Mar 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| General Medical Council | Response publishedPublished on judiciary.uk in March 2023. |
| National Trading Standards | Response publishedPublished on judiciary.uk in March 2023. |
| Royal Society for the Prevention of Accidents | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 24 May 2023. A reply may have been sent and not yet published. |
| Decathlon UK | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 24 May 2023. A reply may have been sent and not yet published. |
The coroner’s concerns
Awareness of Immersion Pulmonary Oedema in the medical profession: i.) Concerns were raised by the medical witnesses that there is very little awareness of Immersion Pulmonary Oedema in the medical profession and that it is not addressed in medical training, as a consequence, it can be missed by those treating the condition and is often mistaken for drowning. The Full Face Mask ii.) iii.) iv.) v.) vi.) vii.) viii.) ix.) x.) xi.) At the time that the Easybreath full face snorkel mask was developed by Decathlon there were no United Kingdom or European Standards which were applicable to a full face snorkelling mask. In the course of its development, Decathlon commissioned a number of tests to be undertaken on it, but it was accepted in evidence that the tests undertaken did not replicate the conditions of the use of the mask by the general public. Decathlon have sold over 16 million of the masks. Other such masks are also on the market. The Decathlon usage instructions for the full face mask, contained in small print, have been amended over time. From the 17th August 2015 the instructions included a warning that you must make sure that you are in good physical condition before snorkelling and that the mask is not suitable for swimming. Further tests were undertaken and an Ergomedical report considered the issue of whether use of the mask and inhalation through the mask’s dead space gave rise to excess carbon dioxide inhalation. The report concluded “we strongly recommend to advise against wearing Easybreath masks to people who suffer from underlying cardio-respiratory conditions.” As a result, Decathlon amended their instructions for use to include that the mask should not be used if the user has unstable cardio-respiratory pathologies, that the mask is to be used under conditions of submaximal exercise (mild to moderate) and that it is not suitable for active swimming. Development of a United Kingdom standard in relation to this type of mask is now being put in train but has not yet begun and is likely to take some time. Decathlon have recently updated their website in the United Kingdom to include the following, “It is not recommended to use this product if you have any ongoing respiratory or cardiovascular issues including but not limited to chest infection, asthma, high/raised blood pressure (hypertension), heart disease or angina etc. If you have any doubts or questions relating to this please check with your medical practitioner." The same additional wording is being translated and added to all websites of the company. The packaging of the mask has been revised to show a pictogram to warn against use of the mask by those with heart or other cardiovascular conditions. The concern is that many million of the full face masks have been sold and the safety concerns about their use by those with ongoing cardiovascular and respiratory issues has not been widely publicised or brought to the attention of those who already own the masks. Those purchased before 2017 had no warning is relation to these matters and the warning included in the instructions from 2017 inwards was not prominent nor sufficient to alert prospective purchasers to the hazards of use which have now been identified. i/ 2
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2023-0109
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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