In the space of 25 seconds, schoolboy Ethan Fitzpatrick went from happily snorkelling around Lake Rotomā to fighting for his life.

The 16-year-old student, a well-liked pupil at Kawerau’s Tarawera High School, was a competent swimmer. He had just completed a snorkelling competence assessment for his Year 12 NCEA qualification and was on another school snorkelling trip with other students when tragedy struck on March 19, 2020.

The teen inhaled water while his buddy briefly had his back turned and after being found kicking wildly in the water he was grabbed by a teacher and dragged back to shore where students watched as an off-duty fire officer and school staff performed CPR.

Despite their best efforts, and that of emergency service workers who arrived soon after, the teen, described by his whānau as “funny” and “intelligent” didn’t survive.

In a determination released today, Coroner Matthew Bates concluded he drowned, and while planning of the trip and supervision of the activities appeared sound, further guidance is needed for recreational snorkelling.

According to the report, the students ventured out around 20m into the lake, where a teacher had earlier placed a buoy marking the ‘no-go’ zone. The deepest point where the students could snorkel was 4m.

Fitzpatrick was paired with a snorkelling buddy and obeyed the ‘one-up-one-down’ rule, which meant at least one of the pair was above the surface watching while the other was diving.

Fitzpatrick’s snorkelling partner swam towards a supervising teacher, asking if the pair could be assessed on their snorkelling skills next.

16-year-old Ethan Fitzpatrick died while on a school snorkelling trip at Lake Rotomā. Photo / Stephen Russell

The student buddy had his back turned to Fitzpatrick for 15-25 seconds, during which Fitzpatrick was not being supervised by anyone.

When his partner turned around, he found Fitzpatrick had rolled onto his side underwater, appeared to be panicking, and was kicking wildly.

He returned to the surface gasping for breath, accidentally kicking one of the in-water supervising teachers as he flailed about.

The teacher grabbed Fitzpatrick by his ankle, asking why he kicked him.

“It became obvious he was distressed. His eyes were fixed open and staring,” the determination says.

The teacher immediately rolled Fitzpatrick on his back and undid his wetsuit, thinking it was too tight around his neck. The other students were ordered out of the water.

The teacher and the snorkelling buddy carried the now unresponsive student to shore.

During CPR, Fitzpatrick appeared to breathe on his own for short periods before stopping. An ambulance and rescue helicopter arrived, and resuscitation efforts continued for an hour. Fitzpatrick couldn’t be revived.

“The evidence suggests that while Ethan was briefly unobserved, he somehow got into difficulty and inhaled water. After inhaling water, he was unable to draw another effective breath. As a result, his heart eventually stopped beating.”

Bates ruled out a medical event being the cause of death.

As the young man lay in his coffin being carried out from his funeral in Kawerau days later, the Prime Minister announced the country was going into Covid-19 lockdown.

Snorkelling safety plan needed - coroner

After the death, Worksafe launched an investigation. It found Tarawera High School (THS) had contravened the Health and Safety at Work Act, due to a lack of effective emergency planning and supervision.

Immediately afterwards, the school’s safety systems were reviewed and updated and further staff training completed. Coroner Bates said the school took appropriate steps, and there was no need to make further recommendations to the school.

But some matters, he said, warranted further publicity.

Bates said that there is no set ratio of teachers to students in education outside the classroom (EOTC) activities, and they are assessed on a case-by-case basis.

On this trip, the ratio was one teacher to seven students, but at times, the ratio was 1:1 for the student being assessed, and 0:14 for the remaining students, while the on-shore supervisor prepared students’ food.

Ethan Fitzpatrick with his mother, Barbara Kinley. Photo / Supplied

That second supervisor was 30m away from the shore cooking a barbecue - “hardly an ideal distance from which to closely supervise”, Bates concluded.

But given the equipment worn including buoyant wetsuits, combined with the skill of the teachers, he was not prepared to conclude the supervisor-student ratio was insufficient.

“Again, it remains unclear exactly why and when Ethan initially got into difficulty”.

Bates also noted the patchy cell reception in the area, requiring a teacher to drive up the road to call emergency services. He recommended future EOTC activities plan how to communicate from the site. A satellite phone may be necessary in some cases, he said.

He reached the same conclusion on access to a defibrillator, saying EOTC activities need to consider the proximity of a defibrillator. In some cases, the school may have to provide one.

Bates finally concluded that with Worksafe having no specific guidance for open-water recreational snorkelling, a code similar to that used in the Australian state of Queensland should be developed in New Zealand.

“More specifically in a school setting, [the guidance] may assist schools with effective safety management planning and compliance with the provisions of the Health and Safety at Work Act.”

He encouraged those arranging trips to refer to the Queensland guidance in the meantime.

-Ethan Griffiths, Open Justice