A magisterial inquiry into the death of a Polish diver has found grounds for a hyperbaric consultant to face criminal charges for involuntary homicide.
The inquiry has recommended that the 43-year-old consultant be held accountable for his failures on the day of Krzysztof Białecki’s death on July 6.
If convicted, he could face up to four years in prison and a fine of €11,646.
The report, led by Magistrate Joe Mifsud, concludes that the medical specialist’s absence during critical moments and his reliance on a trainee contributed to Białecki’s death.
The mismanagement of his treatment, including incorrect assumptions about the dive depth and an improper diagnosis of his condition, were further evidence of negligence.
Krzysztof Białecki, 48, died while receiving treatment at the hyperbaric unit, hours after trying to save another diver.
His death followed an unfortunate diving accident involving diver Dominik Dubaj during a dive on the wreck of Le Polynesien, located at a depth of 60 metres off Marsascala.
Both divers were part of a pod of seven who had received the necessary permits from Heritage Malta to explore the wreck.
During the dive, Dubaj, 45, experienced problems, panicked and began an uncontrolled ascent. Białecki attempted to assist him, and both men surfaced without completing their decompression stops.
Dubaj was rushed to Mater Dei Hospital but died shortly after. His death was attributed to a cerebral artery gas embolism and pulmonary barotrauma.
Białecki, though initially stable, later succumbed to decompression sickness.
The inquiry found no negligence on the part of the dive organisers, Dive Shack, or the other divers, noting that all appropriate measures were taken to save the lives of Dubaj and Białecki.
However, the care provided to Białecki at the hospital was scrutinised, particularly the actions and decisions of the hyperbaric consultant in charge.
The inquiry revealed a series of critical errors in the medical specialist’s management of Białecki’s treatment.
Notably, he left the hospital during the crucial moments of Białecki’s care, delegating responsibility to a higher specialist trainee in medicine, who, it was noted, “was still undergoing training and thus ill-equipped to handle complications and make key treatment decisions”.
Although the consultant instructed the trainee to maintain phone contact, advising him not to make major decisions independently, he was absent from the hospital for a prolonged period in the afternoon.
He returned only at 6.40pm, approximately 10 minutes after Białecki suffered cardiac arrest in the hyperbaric chamber.
The inquiry also raises serious concerns about the treatment provided, particularly regarding the consultant’s incomplete understanding of the circumstances surrounding the dive.
He admitted in his sworn statement that he was unaware of the exact depth at which the divers were operating, mistakenly assuming it to be 50 metres when the wreck lies at 60 metres.
This misjudgement led to incorrect assumptions in his treatment approach.
Misdiagnosis over the phone
The inquiry notes how during the initial treatment phase, Białecki experienced difficulty breathing due to low-pressure valves not opening properly.
Although this issue was eventually resolved, the treatment profile was not paused, and the lost minutes were not compensated, resulting in a greater nitrogen load in Białecki’s blood.
This delay, while not the direct cause of death, exacerbated the condition.
The consultant also misdiagnosed Białecki’s condition over the phone, suspecting oxygen toxicity when, in reality, the diver was likely experiencing decompression sickness.
He advised administering Ativan, a sedative, though he incorrectly stated that it was available in injectable form when it is only available in pill form.
While the consultant believed the Ativan was never administered, evidence showed that two 1mg Ativan pills were given to Białecki at 5.10pm.
As the evening progressed, Białecki’s condition deteriorated. At 6.20pm, he became agitated, removed his mask and complained of increased abdominal pain and shortness of breath.
The trainee, who was outside the main chamber, informed his superior of the deterioration. But the consultant, still away from the hospital, declined the trainee’s request to summon an anaesthetist in preparation for CPR.
Białecki suffered cardiac arrest at 6.31pm, and the CPR team was alerted.
The consultant arrived at the hospital at 6.42pm, but by then, the situation had become critical. Białecki was declared dead at 7.10pm.
The consultant has been suspended pending the outcome of the magisterial inquiry.
There is one other known fatal incident in similar circumstances – in 1985, a fully conscious diver entered the chamber for treatment but died later.