Inquest into the death of Matthew Thomas Richell

STATE CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Matthew Thomas Richell Hearing dates: 25 and 26 February 2016 Date of findings: 4 March 2016 Place of findings: State Coroners Court, Glebe Findings of: Magistrate Barnes, NSW State Coroner Catchwords: CORONIAL LAW – manner and cause of death; beach drowning; life guard services File number: 2014/196230 Representation: Counsel Assisting the Coroner- Sgt Samantha Ferguson.

Mr Michael Spartalis and Mr Scott Nash on behalf of Waverley Council.

Findings: - The person who died was Matthew Thomas Richell.

• Mr Richell died on 2 July 2014.

• He died at Tamarama Beach, NSW.

• The cause of his death was drowning.

• Mr Richell died from misadventure when he was swept up against the rocks of a sea cliff by the surf and then carried back into deeper water where he drowned as a result of being incapacitated by head injuries. No action or inaction by any other person contributed to his death.

Table of Contents

The Coroners Act in s81 (1) requires that when an inquest is held, the coroner must record in writing his or her findings as to various aspects of the death. These are the findings of an inquest into the death of Matthew Thomas Richell Introduction On Wednesday 2 July 2014, Matthew Richell met a friend at Bronte Beach to go surfing. He soon got into difficulty. Despite the brave and frantic efforts of his friends and bystanders, he was unconscious when pulled from the water and even the intervention of professional lifeguards and advanced paramedics was unable to revive him.

This inquest sought to explain how the tragedy occurred and considered whether the provision of life-saving services at the beach were sufficient then and are adequate now.

Social history Mr Richell was born in England and met his future wife, Hannah Norman, in London in 2001. They moved to Australia in 2005 and married in 2007. They have a daughter and a son who at the time of their father’s death were 3 and 6 years old respectively. Matthew was just 41 when he died.

Mr Richell was a fit and healthy person with no known diseases or frailties that may have contributed to his death. He drank alcohol sparingly and did not use illicit drugs.

Professionally, he was very successful, being the CEO of an international publishing company. Mr Richell was admired and respected in his profession and had a close circle of friends.

In the summer of 2009/2010 Matthew learnt to surf. He took lessons at the northern beaches for a period of six months after which he continued to surf on his own.

Generally, he surfed the northern beaches such as Freshwater, Narrabeen and Dee Why. He was described as a sensible person in the water who was aware of his limitations and surfed accordingly. He surfed about once a week in the two years leading up to his death.

These few lines give the barest insight into Mr Richell’s life and character. A more detailed review of his life was not a necessary focus of the inquest. Indeed from one perspective, his death is a deeply private matter and the public inquiry into it is an intrusion into the intensely personal. Conversely, he died in a public place, while engaged in a quintessential Sydney activity and the circumstances of the death call into question the adequacy of public safety services. As Ms Norman graciously acknowledged, the inquest provides an opportunity to reduce the likelihood of similar deaths occurring.

When Mr Richell went to work on that sunny winter’s day, his family had no reason to suspect it would end any differently to any other workday. They didn’t imagine they would never see their husband/father again. Wretchedly, his violent, unforseen death means their lives will never be the same. I offer his wife, their children and their families my sincere condolences.

The evidence Circumstances of the death In July 2014, Matthew Richell and Adam Simpson had been friends for approximately 18 months. Mr Simpson had been surfing for approximately ten years and he and Matthew surfed together occasionally. Mr Simpson described Mr Richell as having an adventurous spirit and although he also observed him to be an inherently confident person, he also reported that Matthew “had a good appreciation of his limitations” so that if Mr Simpson suggested doing something Mr Richell was not comfortable with, he would either attempt to dissuade Mr Simpson from the act or do something independently of him.

Some days before 2 July, the two friends had made tentative arrangements to go for a surf on that day. These plans were confirmed during the morning and they agreed to meet at Bronte Beach at 1:30pm.

They met as planned. After viewing the surf conditions from the cliff tops, they decided to surf a break at the northern end of Bronte adjacent to a rocky point that separates that beach from Tamarama. Mr Simpson said they paddled out into medium sized waves consistent with the surf report predictions of 2 – 4 feet. The wind was blowing off-shore. Both men secured their surfboards to themselves by a leg-rope.

When they had been surfing for 10 or 15 minutes, Mr Simpson became aware that when he attempted to catch a wave he was washed close to the rocks and there was a lot of water swirling around that made it difficult for him to return to the desired take off point. He warned Mr Richell of this situation, and his warning was acknowledged.

Shortly after, a large set loomed up and Mr Simpson paddled hard seaward to get beyond where it would break. He then looked towards the shore to see how Mr Richell had coped with this challenge. He was unable to see him in the expanse of white water adjacent to the rocks but saw his surfboard briefly protruding vertically from the water in manner that suggested it was unmanned. Mr Simpson paddled closer to ensure his friend was safe.

He located Matthew upright and treading water, near the rocks. He did not have his board, but he did not seem panicked and had no visible injuries. Mr Simpson asked if he needed help. Mr Richell but did not answer but gave a wave that was difficult to interpret. Mr Simpson became concerned. His friend was being swept northward around the rocky point in turbulent water with sizable waves breaking against the near-by cliff face. He was not trying to swim after his board or away from the rocks.

Mr Simpson saw a fisherman on the cliff-top adjacent to Mr Richell and called out to him to summon assistance. The fisherman was Ralph Murdaca. He frequently fished the location and described the waves on that day as “big”. He said the wind was strong and on-shore.

He had cast his fishing line from the most seaward position on the point and put the rod in a holder. He briefly turned away from the sea. When he looked back he noticed a person in the water in a wet suit directly in front of his position, about 10 metres from the water’s edge. As he watched the person in the water was swept into

a gap in the rocks where the water was particularly turbulent. As the waves sucked back, he was drawn seaward. Mr Murdaca noticed that the person in the water, who we now know was Mr Richell, was not swimming away from what was clearly a dangerous situation and he saw an unmanned board some distance away, closer to Bronte Beach. In an effort to understand what was happening, he asked the swimmer if he was caught on the fishing line and should he, Mr Murdaca, reel it in?

He got no response.

He noticed another person on a surf board also obviously focussing on the man in the water. That second man, obviously Mr Simpson, appeared to be trying to get to the man in the water but he was unable to because of the volatile wave action.

Mr Simpson called out to Mr Murdaca: “Can you get help. I think he’s in trouble.” Mr Murdaca dialled 000 and reported what was happening. The call was switched through to the ambulance service at 1:57pm.

At about the same time, a member of the public went into the Bronte Surf Clubhouse and reported to an administrative staff member that there was a swimmer in trouble off the point. That administration worker telephoned the Bondi Lifeguard control centre and relayed that information to Anthony Carroll, an experienced lifeguard. Mr Carroll asked a colleague to focus the CCTV camera that was located on a tower on top of the Bronte Surf Clubhouse to the area of interest.

Immediately they did so, they saw Mr Richell close to the cliff face and being swept towards Tamarama by the south easterly swell. They realised from his position and his actions that he was in need of urgent assistance.

Mr Carroll donned a rash vest and life jacket and grabbed a two-way radio, while his colleague ran downstairs to connect an all-terrain vehicle (ATV) to a trailer carrying a jet ski. As the ATV was driven to the water’s edge, Mr Carroll ran across the beach.

The life guard on the ATV backed the trailer into the water, Mr Carroll released the tie-down straps and the two lifeguards slid the jet-ski off the trailer. Initially, the craft could not move away from the water’s edge because the waves had receded. The life guards waited for the next set and manhandled the jet-ski into deeper water. Mr Carroll got astride it and powered out through the break and quickly covered the distance of about 2 kms to Tamarama Beach.

A member of the public walking on the beach while the jet-ski was being launched, Chris Aquilina, became concerned that it took too long. He wrote to the court and gave evidence at the inquest. He acknowledged he had no experience in such matters. I readily accept Mr Aquilina was motivated solely by a desire to improve public safety. However, I also accept that a launching of jet-skis on surf beaches is complex. The water level fluctuates widely with tide changes and wave conditions.

Bondi Beach is approximately a kilometre long. The capacity to drive the vessel to various launch points gives added flexibility but there will always be some delay in it getting from the beach to beyond the break no matter where the craft is stored. I am of the view there was no unreasonable and avoidable delay in the jet-ski being launched in this case.

In the meantime, Mr Richell and Mr Simpson continued to be swept north towards Tamarama. Mr Simpson was unable to get close enough to Mr Richell to enable him to get on the surfboard as the surf conditions were very challenging: every time a set of waves broke over the men they were surrounded by foaming, swirling white water that deprived them of control over their direction of movement. One witness described Mr Richell as bobbing like a cork in the waves.

Mr Simpson saw that Matthew had been swept in among the rocks. He decided he had to try and get to him and so he undid his own leg rope and swam towards the rocks where he had last seen Matthew. He managed to stand on a partially submerged rock, hoping to get a better vantage point from which to look for his friend but he couldn’t see him. He yelled out to a group of people who were on the cliff top observing the incident as it unfolded. Someone responded pointing to a large rock that obscured Mr Simpson’s view. Ominously, the bystander also called out; “He’s gone under.” Leigh Jackson was surfing at Tamarama. He saw that the men were in grave danger and came to assist. He had been surfing on the northern side of Tamarama for over an hour and noticed that at about 1.30pm the conditions deteriorated when the offshore wind swung around to the south-east and the ebbing tide reduced the depth of water over the in-shore sandbanks.

He paddled towards Matthew. He saw him trying to clamber out of the water onto a rock at the base of the cliff but, before he could get clear of the water, a large wave crashed into him and the rocks, smashing the swimmer against the cliff-face. The water receded taking Matthew with it. Mr Simpson and Mr Jackson converged on the point as Matthew was drawn away from the rocks by the retreating swell. They found him floating face down. When he was rolled over they saw Matthew had numerous lacerations to his face and head. He was unconscious and unresponsive.

The two men struggled to get Matthew to the beach. Mr Jackson’s flat-mate, Daniel Mills, who had left the water earlier because of the challenging conditions, ran down the beach and into the water to help. They carried Mr Richell a little way up the beach and lay him on his side to enable water to drain from his airway.

At about this point, Mr Carroll arrived on his jet ski and took control of the resuscitation attempts. He had little resuscitation equipment with him. He explained at the inquest he gave priority to getting to Matthew as soon as possible. As a result, he was limited to giving chest compressions. Mr Simpson gave two breaths of expired air by mouth to mouth resuscitation after every 30 compressions. Another local, Dane Westerweller, who had seen Mr Richell being carried from the water, also joined in the resuscitation attempts. After about four cycles of compressions and breaths, Mr Richell regurgitated. He was rolled onto his side so that his airway could be cleared and the CPR was then resumed. Mr Carroll instructed that back-up lifeguards be summoned from Bondi. This was done.

After about another four cycles the paramedics arrived. Their records indicate they reached the patient at 2:11pm. They applied defibrillator pads which showed that there was no cardiac electrical activity. Sadly, Mr Richell was, in effect, already dead when the ambulance arrived. Nonetheless he was given repeated doses of

adrenaline and provided with oxygen, initially via a bag, valve and mask. He was then intubated. Chest compressions were continued. All of this was done in a desperate but ultimately futile attempt to restart Matthew’s heart.

An air ambulance arrived carrying advanced care paramedics and a doctor. They joined in seeking to revive the patient. Sadly, at 2.38pm it was accepted that further attempts were futile and Matthew Richell was declared dead.

Investigation Police arrived at the scene on Tamarama Beach even before the paramedics. As soon as it became apparent that Mr Richell was deceased, an investigation was commenced.

The lifeguard Anthony Carroll was interviewed. He was visibly distressed by the outcome and angry that he had to come from Bondi to render assistance. He strongly voiced the view that there should be a lifeguard stationed at Bronte and Tamarama all year round and the camera surveillance equipment should be improved.

The officer in charge of the investigation obtained the contact details of the various by-standers and obtained detailed statements from them in the following weeks and months.

Those assisting me contacted Waverley Council to investigate the suggestion that there were insufficient lifeguards available to assist swimmers at Bronte and Tamarama beaches at the time of this fatality.

The council confirmed to the Court that in 2014, neither beach had lifeguards deployed during winter months. Instead, lifeguards at Bondi relied on a camera on the Bronte Surf Clubhouse and telephoned calls for assistance to alert them to incidents requiring their response at those other beaches. The council also advised that in April 2015 it resolved deploy two lifeguards at Bronte Beach 365 per year and to provide the same service at Tamarama from midway through September until the end of June. The council indicated that in its view the low patronage at Tamarama in witner did not warrant a year round service and that incidents on that beach could be attended to from Bronte. A camera had been installed on the Tamarama Surf Clubhouse to facilitate this.

Autopsy An autopsy was undertaken on Mr Richell’s body by an experienced forensic pathologist. She found no signs of disease that may have led to death and no evidence of drugs or alcohol that may have compromised his capacity to swim.

There were however, numerous lacerations to the head and face. The pathologist described these as “superficial blunt force injuries” and indicated “no significant head injuries were identified”. However, she acknowledged that they may have caused “a concussion with a period of decreased responsiveness.”

Conclusions Matthew Richell died while surfing with his friend Adam Simpson at Bronte Beach in Sydney. He died as a result of misadventure, but it would be wrong to suggest he was being cavalier or foolhardy at the time. On the contrary, the evidence indicates he was a careful and responsible person who attempted to respond responsibly to his limited surfing experience. Sadly, like so many others, he was caught unawares by the speed at which relatively benign conditions in the surf can become deadly.

The evidence doesn’t allow me to determine what precipitated the fatal chain of events. According to Mr Simpson, Matthew was paddling out through the break when a set of large breaking waves swept over the surfers. Soon after, he was seen in near the rocks without his board. It seems unlikely Mr Richell would have deliberately undone the leg rope connecting the board to him. That suggests he was dumped forcefully by the waves and the leg rope pulled free. That might also explain why he seemed somewhat dazed when Mr Simpson approached him. That was an opportunity lost: Mr Richell needed to get away from the rocks as quickly as possible. Even swimming with the current he could have put distance between himself and the danger. Counter intuitively perhaps, deeper water offered sanctuary.

When he was swept northward around the point towards Tamarama, he was heading towards the safety of the beach. However, the closer he got the to the cliff face, the more danger he was in. There the waves smashed against the rocks and whirlpools formed that even a very strong swimmer could not easily escape. When he was swept up against the rocks, the temptation to try and climb out over them would have been difficult to resist. It was also highly dangerous. The waves were breaking with great force against those rocks.

Sadly, the risks involved eventuated when Matthew was swept against rocks as he was trying to clamber out. It seems likely he then suffered head injuries and either lost consciousness or was so incapacitated he couldn’t keep himself above the surface and inhaled water. Various mechanisms would have caused his heart’s rhythm to be disrupted, leading to cardiac arrest.

The bravery of his friend, Adam Simpson, in abandoning his surf board and diving into the maelstrom was highly praiseworthy. He placed himself in significant danger to try and help Mr Richell. The willingness of Leigh Jackson, Daniel Mills and Dane Westerweller to lend assistance was also commendable.

They did all they could to get him ashore and they commenced resuscitation. The arrival of the professional lifeguard, Anthony Carroll, was timely. I have concluded there was no undue delay in the launching of the jet-ski at Bondi Beach. He also performed admirably and the following comments should not be taken as being in any way critical of him.

Mr Carroll explained that when he left Bondi, he did not take with him an automated external defibrillator because his focus was on getting to the scene as quickly as possible – he could see on the CCTV that Mr Richell was in urgent need of assistance but he was conscious and supporting himself in the water. I expect a defibrillator was readily available in the lifeguard central control room at Bondi. It’s difficult to conclude that the few seconds needed to grab the case and stow it on the

jet-ski would have contributed to material delay. Generally speaking, the sooner defibrillation is commenced, the greater the chances of successful cardioversion.1 However, defibrillation can only be utilized to respond to particular types of dysrhythmia and these are rarely found drowning victims.2 Certainly, by the time paramedics arrived with a defibrillator, Mr Richell did not have a shockable rhythm. I am satisfied the attempts at resuscitation gave Mr Richell the best chance of recovery. Sadly, he did not respond.

I readily accept the evidence of Mr Carroll that had a lifeguard been on-duty at Bronte Beach at the time of the incident, he or she would have responded to Mr Richell’s predicament utilizing a rescue board, soon after he got into difficulties. I accept that it is very likely they could have brought him ashore safely.

The Waverley Council had determined that the low level of patronage at Bronte and Tamarama during winter months meant that an adequate level of service could be provided by lifeguards stationed at Bondi. They have since revisited that issue and lifeguards are now at Bronte all year round and at Tamarama from September through to June. I am satisfied that with the assistance of cameras at both beaches and the ability of extra personnel from Bondi to quickly attend, that is likely to be sufficient to effectively monitor the area.

Accordingly, I do not consider there are any recommendations arising from the facts of this case that would contribute further to increased public safety.

Findings required by s81(1) As a result of considering all of the documentary evidence and the oral evidence given at the inquest, I am able to confirm that the death occurred and make the following findings in relation to it.

The identity of the deceased The person who died was Matthew Thomas Richell.

Date of death Mr Richell died on 2 July 2014.

Place of death He died at Tamarama Beach, NSW.

Cause of death The cause of his death was drowning.

1 Defibrillation carried out within 3 - 5 minutes of cardiac arrest can have 49 – 75% survival rate that diminishes with each minute of delay by 10 – 12%. See Brown A F T and Cadogan M D, Emergency Medicine, Hodder Education, London, 6th edn. 2011, p13 2 Beerman S, and Lofgren B, Automated external defibrillators in the aquatic environment, p332 and Australian Resuscitation Council, Guideline 9.3.2 Resuscitation of the drowning victim, March 2014, p3

Manner of death Mr Richell died from misadventure when he was swept up against the rocks of a sea cliff by the surf and then carried back into deeper water where he drowned as a result of being incapacitated by head injuries. No action or inaction by any other person contributed to his death.

I close this inquest.

M A Barnes NSW State Coroner Glebe