Experienced instructor, Nigel Craig, was wrongfully prosecuted for the tragic death of his student, but perhaps neither of these things needed to happen, had the dive community been more aware of the dangers of Immersion Pulmonary Oedema
By DIVE’s Senior Correspondent and former Instructor,
On Sunday, 24 July 2016, dive instructor Nigel Craig began a PADI Deep Specialty course dive for Richard Stansfield, a 40-year-old Advanced Open Water certified diver. Tragically, it would be Stansfield’s final dive, and the beginning of a hellish chapter in Craig’s life as he was prosecuted for his student’s death – a death for which Craig was not responsible but one which, with hindsight, was perhaps preventable had the diving community been more aware of a condition now thought to be among the most common – if not the most common – causes of death in scuba diving.
THE DIVE
Stoney Cove, a disused, flooded quarry in Leicestershire, UK, is a popular dive site and one with which Nigel Craig, himself a veteran diver of 20 years, was intimately familiar. He learned to dive at Stoney Cove in 1996, subsequently making hundreds of dives there as both a diver and volunteer instructor for his local dive centre, Dive Northampton.
It was the second dive of the PADI Deep Specialty course, the first of which Richard Stansfield had already completed during his Advanced Open Water programme. The course helps divers to better understand the effects of pressure at depth; how increased air consumption and nitrogen loading necessitate shorter dive times; how narcosis can affect diver judgement; and the importance of making safety stops to mitigate the potential for decompression sickness.
The maximum allowable depth of the dive is 40m, and includes a short navigation swim before making a free ascent using gauges or a dive computer to maintain a safe ascent rate. The course standards mandate a three-minute safety stop at five metres before surfacing.
Stansfield was Craig’s only student that day, and was accompanied by divemaster Karol Tokarczyk, with whom he had dived previously, and with whom Craig had worked several times before. After the briefing and safety check, the team swam approximately 100m to a descent line marking the ‘Hydrobox’, a 35m-deep metal structure used for commercial diver training, which recreational instructors use for deep dives.
The team stopped at the marker buoy to allow an out-of-breath Stansfield time to recover after the surface swim. It took around ten minutes more to reach the dive’s maximum depth of approximately 32m, as Stansfield had problems equalising. Craig took an air check at the bottom, and Stansfield indicated he had 150 bar remaining in his 12-litre cylinder, having started the dive with 250. Craig and Tokarczyk were using 12-litre twinsets, plenty for both themselves and as a contingency supply if necessary.
Stansfield struggled with his buoyancy during his first attempt at the navigation exercise, so Craig cut him short to repeat the skill, which he did successfully. At this point, Craig performed a second air check, and received a signal for 60 bar in response.
This was much less than Craig had expected, based on his earlier check, so he immediately ended the dive and began the ascent, instructing Tokarczyk to continuously monitor Stansfield’s gauge on the way up. At about 18m, Stansfield indicated he was out of air, despite at least 20 bar remaining in his tank.
‘More than four years after the tragic events … Craig received a letter informing him that he would be prosecuted for manslaughter’
‘There was no indication of any heavy breathing,’ said Craig, ‘no sign of panic, nothing like that, so I decided to swap him on to Karol’s alternate.’
Seeking reassurance from his student, now breathing from the divemaster’s twinset, the group continued to ascend, but Stansfield signalled once again that he was out of air. Craig was confused.
‘I purged the regulator, checked Karol’s regulator, and everything was fine,’ he said. ‘Then we had another out- of-air and so I decided to put him on mine. We did the standard ‘look at my eyes, calm down’ signals. I knew I had plenty of air, I knew [my regulator] was working, I got okays and carried on up.’
Approaching safety-stop depth with an air-sharing diver who had indicated he was okay and appeared calm, and with a more than adequate reserve of air, Craig judged it prudent to continue with the planned safety stop – it is a requirement of the course, and standard practice for recreational diving.
Two minutes into the safety stop, Stansfield appeared to panic and tried to bolt for the surface, so Craig reached out to prevent his student making an unsafe ascent – during which the regulator from which he was breathing would have been pulled from his mouth.
‘I held him at the safety stop, made eye contact, checked our computers – we had about a minute or so left,’ said Craig, recounting the final moments of the dive. ‘I took a second to think: What’s just gone on? I didn’t understand why he’s saying he’s got no air when he’s got air; Karol’s checked his regulator – fine. Mine’s working – fine.
‘Then, I looked up and his eyes have gone, glazed, and his regulator’s out of his mouth,’ Craig continued. ‘I indicated to Karol, “I’m going”. I took him [Stansfield] to the surface. I filled his BCD, and mine; Karol took his weights off, I shouted for help and started rescue breathing.’
Craig and Tokarczyk’s unconscious student was taken to shore by Stoney Cove’s rescue boat, where he was resuscitated by paramedics and taken by ambulance to hospital.
Despite the best efforts of the medical staff, however, Stansfield was pronounced dead some five hours later.
THE COURT CASE
Craig was interviewed by police in the aftermath of the incident and attended a voluntary interview in 2017 to clarify details of his original statement, but he was never treated as a suspect.
A British Health and Safety Executive (HSE) investigation found that neither he, nor Dive Northampton, had any case to answer.
Craig and his wife, Della, moved on with their life as best they could until, in September 2020 – more than four years after the tragic events of July 2016 – Craig received a letter informing him that he would be prosecuted for Gross Negligence Manslaughter.
‘I was knocked backwards,’ he said. ‘I didn’t know what was going on.
I met with Nigel and Della, and their legal team, Lisa Morton and James Heyworth – both experienced divers themselves – and the details of the case brought by Leicestershire police, for no reason they have given, are blood-boiling in the misrepresentation of both Craig’s conduct and the safe diving practices used by millions of recreational divers every year.
‘Scuba diver died after instructor held him underwater for ‘safety stop’ at Stoney Cove,’ read the headline in the Leicester Mercury. ‘The divemaster insisted on a non-essential three-minute stop at 5m below the surface, despite the student’s breathing difficulties, a trial heard.’
The prosecution appears to have based its entire case on the idea that Craig had held his unwilling student underwater in the misguided belief that a safety stop was more important than preventing him drowning.
‘That became the focus of the trial,’ said Morton, director of Morton’s Solicitors, based in Stockport, Manchester. ‘It was conceded by the prosecution during the course of the trial that there was no issue with the planning of the dive and the way it was executed up until this point.’
The concession regarding the planning of the dive was only made after a damning rebuttal of the prosecution’s central witness, former Ministry of Defence Superintendent of Diving, Commander Christopher Baldwin.
Cmdr Baldwin’s report into the incident tried to implicate Nigel’s dive plan as the starting point for the fatality. Using the ‘rule of thirds’, he said, Nigel should have ended the dive as soon as they reached their maximum depth, when the student signalled he had 160 bar remaining.
While the rule of thirds is an essential gas-management plan for technical and cave diving, it is mostly meaningless in the recreational world, where a direct ascent to the surface is – with the exception of specialist wreck and cavern dives – possible at all times.
Dive computer records submitted as evidence showed the student had misreported his air supply by as much as 30 bar during the first air check, which the prosecution told the jury was Craig’s fault for not directly observing his student’s computer.
Cmdr Baldwin – despite himself being a PADI certified divemaster – insisted that both the plan and the dive had violated the established no-decompression limits of a dive to 32m, referring to the PADI/DSAT recreational dive planner’s (RDP) maximum limit of ten minutes for a 40m dive.
Brilliant though the RDP was, in its day, its relevance to diving has been rendered obsolete by several decades’ worth of dive computer development, and all three divers were wearing dive computers.
‘I have been on both ends of the octopus, and I know of no instructor who would skip a safety stop after a 30m dive, with an adequate supply of air available’
The crux of the prosecution case, however, was that the safety stop was not necessary, and that Craig should have ascended to the surface with his ‘out-of-air’ diver.
‘All divers were in a ‘non-stop’ dive profile, and an ascent straight to the surface was possible without undue risk of DCS,’ said Cmdr Baldwin, in a quote taken from the prosecution’s opening statement (which in itself seems bizarre, given that he had previously suggested Craig had deliberately set out to violate no-stop limits with his dive plan).
‘This demonstrates that [Nigel Craig] failed to correctly prioritise the most significant hazard (out of air) and consequently did not act competently… I do not believe that another instructor would have risked the safety of a student diver by stopping the ascent to conduct a procedural safety stop.’
‘This incident,’ concluded Cmdr Baldwin, ‘resulted from a failure to adhere to fundamental safe diving practices.’
The attempts to denigrate Craig’s competence – an experienced instructor of ten years, with more than 2,000 dives under his belt at the time of the incident – do not appear to be based on the facts, and suggest that the prosecution brought its case with little knowledge of modern-day recreational diving practice.
For a start, there was no out-of-air emergency. Although the diver had signalled as such, there was still air in his tank. He was breathing from an alternate air source with a plentiful supply and with a second on standby.
Secondly, while safety stops may not be obligatory in the same way that decompression stops are required by technical divers, they are considered essential by the vast majority of recreational divers, regardless of depth.
Safety stops are mandated by PADI (and other agency) training standards from as early as entry-level courses – especially deep-diver programmes – because, ultimately, they help to minimise the risk of decompression sickness, to which recreational depths, no-stop limits and slow ascents are not an absolute barrier.
Finally, surfacing a low-on-air diver, and making a safety stop while air sharing, is a common occurrence in recreational diving. Perhaps, in an ideal world, that should not be the case, but I have been on both ends of the octopus, and – as a former full-time instructor myself – I know of no dive professional who would skip a safety stop after a 30m dive, with an adequate supply of air available.
Dive computer printouts submitted as evidence to the court suggest that a small burst of air was released from Stansfield’s tank during the safety stop, which the prosecution’s expert witness concluded was air being put into his jacket. In what seems like an attempt to further denigrate Craig’s competence as an instructor, the prosecution alleged that Craig had deliberately controlled his student’s buoyancy to keep him underwater while he drowned:
‘I cross-examined the prosecution expert, [taking] the approach that, without any evidence of Karol or Nigel operating Richard’s BCD, it was a reasonable inference that this was Stansfield fine-tuning his own buoyancy at the safety stop – i.e. he was conscious and controlling his buoyancy,’ said Heyworth. ‘The prosecution were cross-examining Nigel on the basis that he had put air into the unconscious diver’s BCD to keep him [underwater], while he drowned, before taking him to the surface.
‘The idea that even if Nigel had completely lost his mind, that his divemaster would sit back and let him do that, is ridiculous.’
Much of the prosecution’s case was debunked by expert technical, military and cave-diving instructor, Kevin Gurr, who noted in his report for the defence that the dive team had a more than adequate emergency air supply, its use was ‘a sensible risk-reduction exercise’, and because the diver was breathing and appeared calm during the air-sharing ascent, Craig ‘may have considered the safety stop appropriate.’
Once the closing arguments had been made, Craig and his wife had to wait two days while the jury deliberated.
‘Time just stopped,’ said Craig. ‘I was treated like a criminal; it’s like you’re made to feel like you’re not human.’
With no news coming from the court, the couple discussed their financial future on the assumption he would be jailed.
Two days of deliberation resulted in a hung jury. The prosecution, for reasons known only to themselves, decided not to opt for a retrial, and the judge directed a verdict of ‘not guilty’, but for Craig and Della, the damage had been done.
Craig – a builder by trade – lost his sole source of income as he could not cope with working through the month-long trial. He, Della and their two children have since struggled through an ‘emotional roller-coaster’, not knowing if their husband and father would be imprisoned. The local dive community lost an experienced and well-regarded instructor.
‘I will never teach again,’ says Craig. ‘I would like to dive again – probably not in this country – but when I was out in Menorca last year, I did a bit of snorkelling and even that messed with my head.
It’s a bit like having a car accident – it can take a bit of time to get back in your car. Maybe it’s a similar thing to PTSD. I don’t know. I get very emotional, very easily now, which was never the case before.’
DID ANY OF THIS NEED TO HAPPEN?
In taking on Craig’s case, defence barrister James Heyworth – a PADI divemaster and former military diver – recognised that some of the circumstances surrounding the incident pointed to a medical condition he had encountered during a previous case.
A diver signalling out-of-air when they still have a working supply is a recognised sign of Immersion Pulmonary Oedema (IPO), a condition where the lungs spontaneously fill with fluid upon immersion in cold water, which, if untreated, eventually causes the diver to asphyxiate.
It is most likely to occur in people with hypertension (high blood pressure); women are eight times more likely to suffer IPO than men; and, unless an autopsy pays particular attention to a very specific part of the lung’s tissues, it is usually mistaken for drowning.
IPO was first described by Dr Peter Wilmshurst, a senior member of the UK Diving Medical Committee, in 1989, but the dive community has been slow to recognise its dangers, so even as late as 2016, very few people knew anything about it.
Called as an expert medical witness during Craig’s trial, Dr Wilmshurst stated that he believed ‘[with a] degree of certainty… greater than the balance of probability and approaching beyond reasonable doubt,’ that Stansfield had succumbed to IPO, although he acknowledged he was ‘concerned about the lack of some information.’
The doctor who had performed the original autopsy died before the trial began, and medical evidence that might have conclusively proved that it was an IPO was unavailable.
Crucially, however, Stansfield had been diagnosed with high blood pressure, for which he was taking medication, and which he had failed to declare in his medical declaration prior to taking the course.
He was also found to have traces of alcohol and cocaine in his system, although it was not known if these might have had any bearing on the circumstances that led to his death.
The prosecution largely ignored that IPO was a possibility, claiming that it was not relevant because Stansfield’s hypertension was controlled, even though this was rebutted by Dr Wilmshurst, who testified that hypertensive divers remain at risk, regardless of any medication they might be taking.
It is not my intention to engage in victim-blaming. Failing to self-declare medical conditions is, unfortunately, quite common in recreational diving, and it may be the case that Stansfield thought his medication meant that his high blood pressure was no longer a risk.
Perhaps, however, if Stansfield had been more aware of the dangers of IPO in relation to hypertension, he would have been more likely to declare it on his medical declaration. He would have had to see a medical referee and perhaps, by doing so, would have mitigated that risk.
Perhaps, if Craig had been more aware of the signs and symptoms of IPO, he would have skipped the safety stop, or would have ended the dive earlier, or even
– because his student was breathless after a relatively easy surface swim – aborted the dive before it began.
That’s a lot of ‘perhaps’, because in 2016, nobody involved knew what IPO was. Had I been the instructor on that course, I would have done exactly the same as Craig.
After 2018, however, I might have done things differently. It was then that I first learned about IPO, after BSAC reviewed its Incident Report database following a 2017 presentation by Dr Wilmshurst, and found that IPO may have been responsible for more than 180 incidents (not all fatal) between 1997 and 2018.
Signs and symptoms of IPO in scuba divers
- Breathing difficulties including rapid, heavy or uneven breathing, or coughing uncontrollably, when not exercising strenuously
- Confusion, swimming in the wrong or a random direction
- Inability to carry out normal functions, while appearing to have to concentrate on breathing
- Belief that a regulator is not working properly, or indicating one is out of gas when they have an adequate supply
- Rejecting an alternate air source
- Indication of difficulty of breathing at the surface.
- Uncontrollable coughing at the surface accompanied by frothy sputum which may contain blood
It’s easy to say that, with hindsight. However, having taken an interest in IPO – particularly as a hypertensive, at-risk person myself – when Craig’s barrister first contacted me about this case, as soon as he mentioned the diver signalling out-of-air with a functioning regulator, IPO sprang immediately to mind.
I believe it is essential, therefore, that divers are informed of this condition, from entry-level training onwards, in the same way that decompression illness and nitrogen narcosis are covered.
To that end, I asked the four largest UK agencies if they planned to include IPO in their training materials. BSAC told me IPO is already included in its entry-level training programme; RAID will roll it out during the first half of 2023; and SSI already includes IPO in its Extended Range (XR) programmes. PADI declined to comment at this time, but I have no doubt they would follow if more agencies make IPO a standard element of their training materials.
‘A diver signalling out-of-air when they still have a working supply is a recognised sign of Immersion Pulmonary Oedema’
Nigel Craig should never have been prosecuted. He was not responsible for the death of his student, but the simple truth of the matter is that in July 2016, a diver died, and it is possible that if more had been known about IPO at that time, it might not have happened.
Furthermore Nigel, Della, Lisa, James – and I – are certain that if this message does not reach the diving community, then there will be further needless deaths.
For all the trauma he has been through, Craig is keen to prevent what he, his student, and his divemaster experienced from happening again.
‘The main thing is getting the message out there,’ he told me. ‘On the day, I’d never even heard of IPO, but a lot of this could have been avoided if that knowledge had been out there.’
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