Inquest into the death of KATHLEEN BAIN HENDERSON

CORONERS COURT OF THE AUSTRALIAN CAPITAL TERRITORY Case Title: Inquest into the death of

KATHLEEN BAIN HENDERSON Citation: [2021] ACTCD 4 Decision Date: 2 August 2021 Before: Coroner Theakston Decision: See [12], [19] & [21] Catchwords: CORONIAL LAW – Cause and manner of death – matter of public safety – serious head injury arising from a fall – recommendation to conduct joint risk assessment Legislation Cited: Coroners Act 1997 (ACT) File Number(s): CD 107 of 2019

CORONER THEAKSTON:

1. The death of Kathleen Bain Henderson was reported to me. She appeared to have died due to a fall. The Coroners Act 1997 requires deaths which appear to be directly attributable to an accident to be reported to the Coroner.

2. At the request of her family, the content of these reasons have been restricted to what is strictly necessary to explain my findings and recommendations.

Circumstances of Death

3. At the time of her death, Mrs Henderson was 85 years old. She did not have a history of falls.

4. On 1 May 2019, Mrs Henderson travelled by bus to, and then from, a community centre. At the end of her return trip, and after the bus had stopped at her driveway, she fell backwards from the bus. This occurred through the open doorway, with her legs remaining in the stairwell. She hit her head on the ground and became unconscious.

5. An ambulance attended and Mrs Henderson was transported to Canberra Hospital.

Mrs Henderson underwent tests but did not regain consciousness. Mrs Henderson was declared life extinct at 10:15 pm that same day.

Manner and Cause of Death

6. The bus was operated by Communities@Work, a private organisation that provides support services to the Canberra community. ACT Police interviewed the bus driver and two passengers.

7. The driver explained that Mrs Henderson’s residence was the first stop on the bus route to return clients to their homes. He stated that he stopped the bus at her driveway. The passenger folding door automatically opened and the driver exited the bus to retrieve Mrs Henderson’s walker. The walker was stored at the rear of the bus.

8. The driver described having walked halfway down the outside of the bus, on the lefthand side, when he heard a loud noise. He turned around and saw Mrs Henderson laying on the concrete driveway, with her legs in the bus stairwell.

9. A passenger described to police that she was seated in the front right-hand passenger seat of the bus and that Mrs Henderson sat to her immediate left. Those two seats were located opposite the passenger side door. The passenger described the bus stopping, Mrs Henderson standing up, Mrs Henderson attempting to grab a cushion while holding the witness’s hand. Mrs Henderson took a step back and fell directly out through the stairwell of the bus, striking her head on the driveway. Another passenger also witnessed the incident and confirmed the first passenger’s account.

10. The driver called an ambulance, which attended and transported Mrs Henderson to Canberra Hospital. She was assessed to have a Glasgow Coma Score of 5, which is consistent with a serious head injury. A CT scan was performed. That scan depicted a serious head injury, which was not considered survivable. A decision was made to provide only palliative care and Mrs Henderson died shortly thereafter.

11. At my request, Professor Johan Duflou conducted an external examination of Mrs Henderson and reviewed the medical records. He opined that Mrs Henderson died from a head injury due to a fall. He also assessed that the treatment provided to Mrs Henderson was appropriate given the nature of her injuries.

12. I am required to make findings as to the identity of the deceased person, when and where they died, and the manner and cause of their death. I find that Kathleen Bain Henderson died on 1 May 2019 at Canberra Hospital, Yamba Drive, Garran, in the Australian Capital Territory, and that the manner and cause of her death was a head injury due to a fall from a bus.

Matter of Public Safety

13. Paragraph 52(4)(a) of the Coroners Act 1997 provides that a Coroner must state whether a matter of public safety is found to arise in connection with an inquest, and if so, a Coroner must comment on that matter.

14. Following the incident Communities@Work quickly and appropriately accepted recommendations by WorkSafe and implemented protocols to address the risk of a

passenger falling from one of their buses through the side door. Those protocols were consistent with protocols already implemented by Transport Canberra, and included: a. the placement of safety signs on each bus informing the passengers to remain seated until the driver is present to assist; b. drivers reminding passengers to remain seated until the driver is present to assist; c. bus doors remaining closed on arrival at destinations; d. bus doors being opened by the driver using the external switch once the driver is present to assist; e. when a passenger is to exit via the rear door and lift, the side passenger door is to remain closed; and f. refresher training covering the introduction of the protocols be given to all bus drivers engaged in the transportation of elderly passengers.

15. The buses used by Communities@Work are provided by Transport Canberra and City Services and are supplied with all modifications already completed.

16. Since the incident there has been a change in the bus model provided to Communities@Work. The new bus does not have an external switch to operate the side door. That was identified by Communities@Work as a risk. They consequently placed a plastic yellow chain across the doorway to act as a visual reminder for passengers not to approach the door without the driver’s assistance. I am not persuaded that the use of the plastic chain would, in all the circumstances, be an adequate control for the risk of an elderly passenger falling out of the bus.

Communities@Work also maintain other controls, including signage directing passengers to remain seated until the driver is ready to assist them in alighting from the bus.

17. Mrs Henderson’s family expressed concern about the elevated seat Mrs Henderson had been seated on and the associated step located immediately to the left of that seat, between the seat and the stairwell. It appears that only one seat in the bus is elevated in that manner. The family submitted that the door being open and the presence of that step contributed directly to Mrs Henderson’s fall, the severity of the injury she suffered and ultimately her death.

18. Unfortunately, the evidence is not clear enough for me to make a finding about whether that step contributed to the fall. However, the presence of that step, so close to the stairwell and an open door, must create the risk that any fall due to that step could result in a fall out through the open bus door.

19. In the above circumstances, I find that a matter of public safety does arise. The use of the seat, located on an elevated step adjacent to the opening side door of the bus, represents a serious risk to passengers with mobility issues.

20. As Transport Canberra and City Services and Communities@Work share the responsibility of providing an appropriate and safe transport service, it is important that the two organisations come together and regularly and jointly consider questions of risk and any necessary controls to ameliorate the risks identified. That approach would allow each organisation to bring to the process its experience, judgment and resources. To do otherwise may unnecessarily limit what risks are identified and what controls are thought to be available.

21. Accordingly, I recommend Communities@Work and Transport Canberra and City Services periodically and jointly conduct risk assessments to address risks associated with the service. In the first instance that should include the risk of passengers falling due to existence of the step and the passenger door. The two organisations should also jointly consider and implement any necessary controls to mitigate those risks.

Such controls may, for example, involve the adoption of protocols by Communities@Work and modifications to the bus by Transport Canberra and City Services.

22. I extend my condolences to Mrs Henderson’s family and friends.

I certify that the preceding twenty-two [22] numbered paragraphs are a true copy of the Reasons for findings of his Honour Coroner Theakston Associate: Linda Cao Date: 2 August 2021