Inquest into the death of Noel Ramage

NORTHERN TERRITORY OF AUSTRALIA CORONERS ACT 1993 Rel No: D0084/2016 Promis No: 7847342 Section 16 Coroner’s Reasons for Decision not to Hold Inquest Section 34 Coroner’s Findings

1. I, Kelvin Currie, Deputy Coroner for the Northern Territory, have investigated the death of:

NOEL P RAMAGE On: 17 May 2016 At: Saltwater Arm River, Northern Territory GPS coordinates S 12o 14.437’ E 131o 10.782’ I have decided not to hold an inquest into that death because the investigations into the death have sufficiently disclosed the identity of the deceased person, the time, place, cause of death, relevant circumstances concerning the death and the particulars needed to register the death under the Births, Deaths and Marriages Registration Act.

2. I do not consider that the holding of an inquest would elicit any information further to that disclosed by the investigations conducted.

SUMMARY OF EVIDENCE Identification

3. On 17 May 2016 the deceased’s body was identified by his friend, Raymond McCumber.

Post-Mortem Examination

4. An autopsy was performed by Doctor John Rutherford Forensic Pathologist on 19 May 2016. His report gives the cause of death as: 1(a) Disease or condition leading directly to death: Drowning

Summary of major pathological findings

• Clear frothy fluid exudation around the lips.

• Fluid in the main airways.

• Oedematous lungs.

• Mild pulmonary emphysema.

• Mild cardiomegaly.

• Mild diffuse left ventricular fibrosis.

• In situ three lead cardiac pacemaker.

• Mild to moderate focal coronary artery atherosclerosis.

• Severe atherosclerosis of the abdominal aorta.

• Previous surgery to the right side of the neck (presumed radical neck dissection).

• Probable previous radiotherapy to the right side of the neck.

• Previous appendicectomy.

Conclusion I have no current reason to believe that death was from anything other than drowning.

Specimens

5. Specimens were taken for toxicology analysis.

Results: Forensic Science Case Number: 1602604

1. Alcohol was not detected in the blood

2. Detected in the blood: (1) 0.33 mg citalopram per L (2) approximately 9 mg paracetamol per L (consistent with therapeutic concentrations) (3) approximately 7 mg phenytoin per L (consistent with therapeutic concentrations) (4) metoprolol (consistent with therapeutic concentrations)

3. No other drugs were detected in the blood

Police Investigation

6. A coronial investigation by Police found no suspicious circumstances surrounding this death.

Circumstances

7. Noel Ramage (the deceased), a 75 year old man was born on 14 November 1940 in Shepparton, Victoria.

He had three children to his first wife Priscilla: Elaine, David and Rodney. He later married Annette. She passed away in 2012.

He had worked for State River and Water Supply in Bendigo, however had been retired for several years at the time of his death.

Noel had been receiving treatment for the cancer, but in early May 2016 he reported to family and friends that he had been given the “all clear” and decided to travel to Darwin for a holiday.

On 14 May 2016 Noel, his daughter Elaine and good friend Raymond (Ray) McCumber travelled to the Northern Territory to visit Noel’s son, David in Darwin. They drove up in Noel’s extra cab utility towing his boat. He spoke of taking Ray crabbing. The boat was a ‘Dolphin’ 13 footer, fitted with a 9.9hp outboard motor. However, he had modified it from its original design by adding panels for side protection (cages) about 570mm high and 2700mm long along both sides of the boat and placed chairs in the boat for seating.

At about 9.00am on 17 May 2016, Noel and Ray drove down to the Saltwater Arm River Boat Ramp. There they installed the side panels on the boat.

Fishermen launching their boat at the ramp noticed the panels and asked about their purpose. Noel replied “to keep the croc’s away from Mac”. The fishermen made a comment about the panels affecting the stability of the boat.

Ray put on a lifejacket. He said he had a fear of water and had never learnt to swim. Noel didn’t put one on. He said he had never needed one.

Ray was seated at the front. Noel was seated at the rear driving the boat. They headed upstream and set their crab pots (eleven in total). A little while later they checked the first pot. There was no crab. They reset the pot and checked the second. Ray missed the rope on the second pot. Noel reached into the water and grabbed it. He turned the motor off and lifted the pot in from the right hand side of the vessel and placed it on the Esky in the middle of the boat. It contained a large mud crab.

As Noel pulled the crab out of the pot he shouted, “Croc Mac. The boat overturned and Ray found himself in the water. He said, “I hadn’t seen or felt anything so it caught me totally by surprise”.

Ray had his lifejacket on and was floating alongside the boat. He could not see Noel. The side panels had been dislodged and the Esky, bucket, the other lifejacket and chair floated away.

Ray said he tried to right the vessel for about two hours. He said he noticed crocodiles in the water and fended them off by throwing objects at them. When Ray righted the boat he found Noel inside. His death was obvious. The boat was full of water and so Ray climbed the bank into the mangroves.

At around 2.00 to 2.30pm, professional mud crabbers noticed that the transom of Noel’s boat was under the water and motored over to have a look. As they got closer, they heard Ray call out to them from the mangroves.

The men observed Noel in the boat floating face down in the water, his legs extending past the transom. They rolled him over and saw he was dead. They drove into the mangroves, pulled Ray into their boat and then towed the boat back to the Saltwater Arm River Boat Ramp.

A ‘000’ phone call was made from the Leaders Creek fishing base (there was no mobile service at the boat ramp). Careflight received the call at 3.19pm and landed at the boat ramp at 3.50pm. Medical staff declared Noel deceased at 3.55pm.

The boat was later inspected by the Principle Marine Safety Officer with the Department of Transport, Sri Srinivas. In his report of 24 August 2016 he stated, “modifications have rendered the boat inherently unsafe to carry 2 persons even in smooth waters. Thus the vessel was unseaworthy for the voyage undertaken.” In effect, the weight and positioning of the side panels exaggerated any weight imbalance. Sitting on the chairs installed in the boat accentuated the issues.

The modified boat took water and capsized relatively easily.

Recommendation I recommend that the Department of Infrastructure, Planning and Logistics alert users of small boats to the dangers of:

• modifying vessels without expert advice or assistance; and

• operating vessels beyond their design capabilities, including exceeding the requirements detailed in an Australian Builders Plate where one is fitted.

I note that it has been a requirement in the Northern Territory since 1 April 2013 to fit Australian Builders Plates to all new recreational vessels sold.

The Australian Builders Plate provides key information on a boat’s capability and capacity and includes detail on boating operations, maximum number of people and load allowed, engine rating and weight.

FINDINGS I find that the deceased is Noel P. Ramage, a male born on 14 November 1940 in Shepparton, Victoria. He resided at 31 Daniel Drive, Kangaroo Flat in Victoria and was retired.

The deceased died about 2.1 kilometres upstream of the boat ramp on Saltwater Arm River (GPS coordinates S 12o14.437’ E 131o 10.782’) on 17 May 2016 at about midday.

The cause of death was accidental drowning.

Dated 9 January 2017 Kelvin Currie Deputy Coroner