A coroner has recommended that defibrillators be included in all Defense Force medical kits after a member of the Special Operations Squad died during a training exercise off the Coromandel Peninsula.
A review of the types of life jackets used by NZDF personnel has also been requested by the coroner.
Sergeant Wayne Taylor, 42, died October 13, 2017 in Port Jackson.
His cause of death was confirmed earlier this year by coroner Robin Kay as drowning in salt water, associated with injuries sustained in a fall from a height.
Coroner Kay’s findings have been made public.
“On the morning of his death, Mr Taylor was one of several New Zealand Defense Force soldiers taking part in a maritime exercise in the Hauraki Gulf,” he said.
“The exercise involved boarding a container ship from a rigid hull inflatable boat while the container ship was underway.
“Around 6 a.m., Mr Taylor was in the dinghy positioned alongside the moving container ship.
“The soldiers in the dinghy attached a portable ladder to a railing of the ship.
“While climbing the ladder, Mr. Taylor fell. It hit the back of the dinghy, before falling into the sea.
Coroner Kay said Taylor’s colleagues located him quickly.
He was floating face down and unresponsive in the water.
“They pulled him into the boat, where CPR and other medical aids were administered by an NZDF doctor who was transferred to the nearby safety boar,” the coroner’s report said.
“The rubber boat then headed to a beach in Port Jackson to meet the Westpac Rescue helicopter.
“Resuscitation attempts at this time did not include defibrillation, as there was no portable defibrillator on board the safety boat.”
Coroner Kay ruled the maritime exercise was “carefully planned and informed”.
“There was no evidence to suggest there was any equipment failure,” he said.
“All staff involved have also been trained appropriately.
“Mr. Taylor has been repeatedly described by his colleagues as a diligent and highly skilled soldier, particularly in the maritime environment.
“Colleagues have also described him as the head of safety standards within the unit.”
The Northern Police Special Tactical Group inspected the ladder used during the exercise and found no abnormalities.
Additionally, Coroner Kay said the portable ladders, their hooks and the carabiner connecting the two had been serviced annually by a civilian company and had up-to-date certification.
“Also, the scale was not overloaded,” he found.
“It was noted that the rail bent and fell approximately 30 centimeters when Mr Taylor climbed on it. However, there was no evidence that Mr Taylor was off balance when this happened. .
“Furthermore, the distance was unlikely to have been significant, occurring at a time when the inflatable boat and the container ship were both moving up and down in the swell.
“Soldiers who had climbed it before Mr Taylor described it writhing under them in the same way.
“The only difference was that when the ladder twisted as Mr Taylor climbed it, it got one of his feet stuck.”
Coroner Kay found evidence suggested Taylor fell from the ladder because he found himself “suddenly unable to hold on” rather than letting go in a planned way.
‘When Mr Taylor fell he hit his head, most likely on the back of the rubber boat,’ he said.
“It was highly likely that Mr Taylor was unconscious when he fell into the sea and therefore could not have avoided drowning.”
Coroner Kay made several recommendations after investigating Taylor’s death.
“The NZDF doctor on the safety boat said he did not take a defibrillator with him on the exercise as it was not normal to carry one ‘on the water'” , did he declare.
“I can’t say if the outcome would have been any different for Mr Taylor had an AED been available, but such devices can be used in humid environments and can significantly increase the chances of survival in the event of a cardiac arrest.
“I recommend that the NZDF ensure that, where operational circumstances do not prevent it, an AED is part of the medical kits carried on maritime operations and exercises.”
He also said Taylor was wearing a life jacket that required him to manually inflate it, but he was unable to do so.
“I recognize that the safety of defense personnel working in a maritime environment could be compromised by a life jacket that inflates when simply splashed with water,” Kay said.
“However, there are life jackets available that are designed to inflate when fully submerged in water and under water pressure, rather than when simply splashed with water – I recommends that the NZDF review the type of lifejacket used by its personnel, with a view to identifying a lifejacket that would meet NZDF operational requirements and could self-inflate to assist an unconscious wearer.
Taylor is survived by his wife and four children.
He had served in East Timor and Afghanistan since joining the Defense Forces in 1997.
Army Chief Major General Peter Kelly said the regiment would remember him as an outstanding soldier.
“He was a consummate professional, known for his dedication and reliability – always upholding our core values in every business,” he said.
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