Coroner Katherine Greig said inexperience and “unsafe diving practices”, including incorrectly assembled scuba equipment, contributed to the tragedy, which happened near East Cape on Christmas Eve in 2022.
“Sadly, I have reached the conclusion that Mr Matthews’ death was preventable,” she said in a report released this morning.
Seafood for Christmas
Matthews, a hydraulic specialist and volunteer firefighter, was diving at Potikirua, Lottin Point, early in the morning of December 24, when he got into difficulties.
Although alone in the sea, the Rotorua man had a friend nearby, fishing from the shore.
Coroner Katherine Greig said Aaron Matthews’ death was preventable. Photo / RNZ
The two had spent the night in their vehicle before getting up early to catch seafood for Christmas.
Matthews checked his diving gear, which he had bought brand new, and entered the water around 6.30am. The weather was calm with no wind.
The friend on the shore said Matthews would surface from time to time during the first 30 minutes and did not look to be in distress.
But about 7am, he came to the surface with his dive mask off and yelled for help, distressed and struggling to breathe.
The friend threw a rope to pull him out of the water as Matthews said words to the effect of “It got me”, and started coughing.
Although Matthews took hold of the rope, he was unable to reach the shore and let go before sinking back underwater.
He resurfaced once more before going under for the final time, and the friend did not see him again.
Aaron Matthews was diving near Lottin Point, East Cape, when he died.
The friend drove 25 minutes to Hicks Bay to get cellphone coverage and raise the alarm.
Police, Land Search and Rescue and Surf Lifesaving were called out, and lifesavers saw bubbles in the water, which they knew from experience would be from diving equipment, about 3.30pm.
Matthews’ body was found in 9m of water, tangled in a pile of sticks and seaweed, facing upwards and not wearing his dive mask.
Police said there was no evidence of foul play and there were no drugs or alcohol in Matthews’ system, other than paracetamol.
After receiving a post-mortem report, the coroner determined that the cause of death was drowning.
Scuba equipment examined
A police National Dive Squad officer, Constable James Kang, who examined Matthews’ equipment, said his diving cylinder had been assembled incorrectly, with a cylinder valve facing away from the diver and not towards him.
This forced the breathing regulators into the wrong position, on the outside of the cylinders and not between the cylinder valve and Matthews’ head.
Kang said this would have created a “tension”, making it feel as if the regulator, which would have been upside-down, was being pulled out of the mouth.
“Constable Kang did a test dive with the incorrectly assembled diving equipment and stated he could not turn his head to the left, otherwise the regulator would be pulled from his mouth,” Coroner Greig said.
Kang concluded this was a contributing factor to the drowning, at the very least restricting Matthews’ visibility and potentially allowing water to be inhaled, which could cause alarm or panic.
Kang also said Matthews’ weight belt was too heavy, and he failed to undo it when in trouble on the surface.
He was not wearing his mask when calling for help, and it was around his neck when his body was found. Kang said taking the mask off in a panic was common.
Aaron Matthews was diving near Lottin Point, East Cape. Photo / Shellie Evans
No training records found
Matthews’ fiancee told police he had completed a dive course in 2020, but had not submitted the paperwork to gain a certificate.
Police inquiries, however, found no records that he had completed a course or training.
Kang considered a lack of dive training may have been a contributory factor.
Matthews’ fiancee said he always went diving on his own, but with someone on shore.
“He had never been out with a dive buddy,” the coroner’s report said.
“Unsafe diving practices identified by Constable Kang were instrumental in his death,” Coroner Greig said in finding that the death was preventable.
“In reaching this conclusion, I record that Mr Matthews was described as a careful person and not a risk taker.
“He was diving on a calm day, near the coastline. He was physically fit and not doing anything apparently reckless.
“Tragically, inexperience and possibly lack of sufficient training, and certainly no recent refresher/upskilling training, resulted in several unsafe diving practices which resulted in his death,” the coroner said.
The coroner said she hoped that drawing public attention to the following recommendations would reduce the chance of similar tragedies in the future.
Divers should:
•Always dive with a dive buddy and remain with the buddy.
•Be thoroughly familiar with, and complete, pre-dive safety checks on their own and their dive buddy’s equipment.
•Abandon their weight belt if in difficulty.
•Constantly review and adjust buoyancy weight to maintain the correct level of buoyancy.
•Dive within their dive experience levels and qualifications.
•Complete recognised training courses – including undertaking a refresher scuba course if not diving consistently.
•Have a dive plan that any support person on shore is aware of. It should include procedures in the event of an emergency and contingency planning for lack of communication or remote accessibility.
‘No fish is worth your life’
Former Navy diver Rob Hewitt, a Water Safety New Zealand (WSNZ) spokesman, described the coroner’s findings as “a heartbreaking reminder that drowning is almost always preventable”.
About eight people die in New Zealand each year as a result of underwater activities, including scuba diving, free diving, breath-holding and snorkelling.
Last year, the victims of all underwater fatalities were men, and three of the four deaths occurred when close buddy contact wasn’t maintained.
“Having a buddy in close contact is the vital help you need if something goes wrong underwater,” Hewitt said.
“Looking after each other might mean collecting a little less kai – but it means everyone will be here to dive another day.”
Hewitt encouraged people to take all of the recommendations from the coroner’s findings seriously.
“Never, ever dive alone. This message cannot be reinforced more strongly.
“Kai gathering increases over summer – and with it the temptation to head out quickly or squeeze in one last dive before Christmas. But no fish is worth your life. Your whānau want you at the Christmas table far more than they want extra kaimoana.”
•Ric Stevens spent many years working for the former New Zealand Press Association news agency, including as a political reporter at Parliament, before holding senior positions at various daily newspapers. He joined NZME’s Open Justice team in 2022 and is based in Hawke’s Bay.