Demographics
29y, female
Date of death
2024-03-29
Finding date
2025
Cause of death
Multiple blunt force injuries due to motor vehicle collision (pedestrian)
AI-generated summary
A 29-year-old woman died after being struck by a vehicle while walking on an unlit road at night after leaving a nightclub event. She had consumed alcohol (BAC 0.15%) and was wearing dark clothing on a dark, unlit stretch of road with an 80 km/h speed limit. Crash investigation determined the driver was sober, not at fault, and travelling at or near the speed limit. The coroner identified preventable system failures: the venue had not arranged a courtesy bus despite knowing patrons would depart intoxicated with limited taxi availability, and the road lacked street lighting. The coroner emphasised that while the deceased's intoxication and poor decision-making contributed, a Safe System approach would have provided protective measures—either safe transport from the venue or adequate road lighting—that could have prevented this death.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Error types
Drugs involved
IN THE CORONERS’ COURT OF THE NORTHERN TERRITORY Rel No: D0080/2024 Police No: 24 85719
CORONERS’ FINDINGS ROAD DEATH 18 OF 2024 Section 34 of the Coroners Act 1993 I, Elisabeth Armitage, Coroner, having investigated the death of a 29-YEAR-OLD CAUCASIAN FEMALE and without holding an inquest, find that she was born on 18 March 1995 and that her death occurred on 29 March 2024, at Melville Bay Road, Nhulunbuy in the Northern Territory.
Introduction 60 persons lost their lives on Northern Territory roads in 2024 compared to a total of 31 lives lost in
Pedestrians are vulnerable road users and pedestrian fatalities represent around 19% of lives lost on Territory roads. Pedestrian fatalities are most prevalent between 6pm and 6am. Since 2019, 97% of pedestrian fatalities were under the influence of alcohol. Where pedestrians are under the influence of alcohol, predictability of movement is a challenging issue and their visibility at night is also a challenge for other road users.5 Shortly after closing time and in the early morning of 28 March 2024, a 29-year-old Caucasian female wearing dark clothing, along with other pedestrians, was walking from the Gove Boat Club (formerly known as the Gove Yacht Club) towards Nhulunbuy (a distance of 12km) along an unlit and dark stretch of road, which had a speed limit of 80km/h. A registered vehicle driven by a licensed and sober 1 Northern Territory Government, Towards Zero Safety Action Plan 2024-2028 2 Fia Walsh, “Disgraceful Road Toll in Crosshairs as NT Road Safety Plan Released”, NT News, 25 July 2024 3 Section 4A of the Coroners Act 1993 4 Section 34(2) of the Coroners Act 1993 5 Northern Territory Government, Towards Zero Safety Action Plan 2024-2028
Caucasian male driver who had been working at the Gove Boat Club was travelling along the same stretch of road towards Nhulunbuy at a speed close to the speed limit.
When the driver came upon the 29-year-old she was in the middle of his lane. He did not see her and struck her from behind. He immediately stopped, called 000 and rendered assistance. Emergency services attended quickly but the 29-year-old could not be revived, and she passed away.
It is not known why the 29-year-old was in the middle of the lane with her back to traffic, but she had been drinking and had a blood alcohol level of 0.15%.
Having analysed the scene, the crash investigators concluded that the average driver, travelling at the speed limit, would not have had sufficient time and distance to avoid the collision and the driver was not charged with any offences.
The Department of Logistics and Infrastructure (DLI, formerly DIPL) understands that human beings can and do make mistakes and poor choices and the Northern Territory Government's stated Safe System approach to road safety is designed to ensure the road system is protective enough to avoid road trauma when mistakes or poor choices are made. Additionally, the Territory Government's Social Model approach "emphasises the importance of understanding human behavior and the role of social factors in shaping road user behaviour" and calls for "a more holistic and multidisciplinary approach to road safety across different sectors and levels of government".
Had the approaches envisaged in the 2024-2028 Towards Zero Road Safety Action Plan been robustly applied to the venue at which the 29-year-old was drinking and to the road on which she was walking, actions could have been taken to reduce the risk. A safe system of public transport, such as a courtesy bus, could have been offered to patrons attending the venue, and if offered, may have reduced pedestrian traffic and the risk of this road death. Additionally, had there been street lighting between the venue and Nhulunbuy this would likely have reduced the risk of this pedestrian death.
Cause of death 1(a) Disease or condition leading directly to death: Multiple blunt force injuries 1(b) Morbid conditions giving rise to the above cause: Motor vehicle collision (pedestrian) 1(c) Alcohol intoxication Following an autopsy on 4 April 2024, the Forensic Pathologist commented:
• The opinion as to the cause of death is based on the available police and medical information, and a post-mortem examination including ancillary investigations.
• At autopsy, the decedent had multiple blunt force injuries with abrasions and lacerations to the body. Cranio-cervical injury with complete or near complete cord transection was seen on radiological examination which may be associated with immediate incapacitation and death indicates a high impact collision injury. The significant blunt force chest, pelvic, and limb injuries also supports a high impact collision injury. Toxicological analysis showed a blood alcohol level of 0.15% which may be associated with loss of co-ordination and balance (motor skills) but there may be person to person variability depending on various factors.
• I have no reason to believe with the information available and findings made during external examination of the body that the death was due to any other cause than the reported motor vehicle collision as a pedestrian.
Circumstances This 29-year-old female pedestrian was born, raised, and worked in Nhulunbuy.
On Thursday 28 March 2024, to kick of the Easter Long Weekend, the Gove Boat Club promoted a free entry, over 18’s, DJ event, called Bad Bunny from 7- 11.30pm. The Manager of the Gove Boat Club estimated that between 200-250 people attended the event and the till takings were just over $7000. The Gove Boat Club (formerly the Gove Yacht Club) holds a liquor licence which does not require them to provide a courtesy bus. However, in preparation for the event, the Manager contacted two bus services but was unable to secure a courtesy bus. The taxis (of which I understand there are two) were available.
That evening, the 29-year-old female pedestrian and her girlfriend met at the Walkabout Tavern in Nhulunbuy at around 10.00pm and they then caught a taxi to the Gove Boat Club arriving at 10.25pm.
They signed the visitor log and purchased drinks which they took outside to the Belvedere structure which had become a makeshift dancefloor with a DJ. During the next hour or so the two friends consumed alcohol and socialised with others on the dance floor and in the club. At 11.28pm the music stopped, and the lights came on, indicating the end of festivities for the evening. The two friends exited towards the front carpark and called a taxi. However, instead of waiting for the taxi they spotted other people walking back towards town and decided to also start walking.
Still taken from CCTV, some of the group exiting the main driveway
Still taken from CCTV, other pedestrians trying to wave down a car for a lift near the Rio Tinto conveyor Still taken from CCTV, other pedestrians trying to wave down a taxi Still taken from CCTV, the deceased, and her friend walking down the road near the Rio Tinto conveyor
It is approximately 12km from the Gove Boat Club to Nhulunbuy, a 12-minute drive or a 2.5-hour walk. From CCTV it is possible to determine that more than 10 people started walking back towards Nhulunbuy.
The two friends and other pedestrians had been walking for about 10 minutes when some of the other pedestrians were picked up by a family member who came to collect them. That person was driving a ute with limited seats available. The 29-year-old became frustrated because there was no room for her and her girlfriend in the ute but, quite correctly, they were not permitted to travel in the tray.
Unbeknownst to the two friends, after dropping off her first passengers, the driver of the ute returned to collect the two friends. Tragically, it was too late.
At 12.15am, a driver was travelling in the direction of the Gove Boat Club, outbound from Nhulunbuy.
He had received a call from friends who were seeking a lift after the Gove Boat Club had closed and who were part of the group that had also started to walk into town. The passing outbound driver saw the 29-year-old and her girlfriend walking along the left-hand side of the outbound lane on Melville Bay Road near Birrtjimi Outstation. They were walking inbound (in the direction of Nhulunbuy) and facing the oncoming traffic. The driver moved to the centre of the road to avoid hitting them. Without finding his friends, the driver then headed back towards Nhulunbuy. He saw the 29-year-old still walking inbound (in the direction of Nhulunbuy) but this time she was towards the centerline of the road, on the outbound lane side while her girlfriend was still on the outbound edge of the road.
Just before 12.24am, the 29-year-old was now walking inbound (in the direction of Nhulunbuy) in the inbound land while her girlfriend was slightly ahead of her and still walking on the edge of the outbound lane. There was no street lighting, and it was very dark. Witnesses described the lighting as "really bad along that stretch." The girlfriend used her phone torch to see, but the 29-year-old did not use any light. The 29-year-old was wearing darkish pants and a dark singlet.
A licensed male driver, driving a registered Holden Rodeo, was driving inbound. Behind him were two other vehicles (vehicles 1 and 2). As the vehicles approached her from behind, the driver said the 29year-old moved towards the centre of the lane and he struck her with the Holden Rodeo. She was projected forward.
Crash location, Google Earth Image, and Police Investigators markings
The driver of the Holden Rodeo pulled over, exited his vehicle, and immediately rang 000 at 12.24am.
The driver in the car immediately behind him (vehicle 1) did not realise there had been a collision and kept on driving.
The girlfriend heard the collision and turned and saw the driver on the phone. Because it was very dark, they could not see the 29-year-old. They used a phone torch to look for her. The next car (vehicle 2) saw the Holden Rodeo pull over and then saw the torch light on the road. The driver of vehicle 2 stopped to ask what had happened and then used his head lights to illuminate the road. The 29-yearold was then found on the dirt shoulder of the road.
A St John Ambulance emergency call operator remained on the phone with the driver and gave instructions concerning CPR. CPR remained in progress until Nhulunbuy Police and St John paramedics arrived at 12.40am and took over. Despite efforts to revive the 29-year-old there were no signs of life, and her death was confirmed at 1.09am on 29 March 2024.
Police immediately breath and drug tested the driver with zero drugs or alcohol detected. The driver cooperated fully at the scene and was very distressed. Concerning the 29-year-old he said, "I wish it was me instead" and "What if she's got a family or kids?".
The collision occurred on a straight sealed section of Melville Bay Road approximately 750 metres east of Wallaby Beach Outstation. The in-and-outbound lanes are delineated with a broken white centre line and there was no painted fog lane marking the road edges. The road has cleared, gravel shoulders with a row of steel power poles and a footpath running parallel with it on the north side of the road.
The speed limit for that section of Melville Bay Road is 80 km/h.
The crash occurred at nighttime, the weather was fine and clear, and, in the absence of street lighting, it was dark.
A post-crash inspection of the Holden Rodeo did not identify any defects that contributed to the collision.
Tests and/or Calculations Conducted A desktop analysis of the crash and the factors involved was completed.
• A pedestrian throw calculation showed the vehicle was travelling between 66.82 km/h and 81.54 km/h at impact.
• The average nighttime recognition distance for a driver in similar circumstances is 30.6 metres which equates to 1.38 seconds for a vehicle travelling at 80 km/h.
• The average perception response time for a driver in similar circumstances is 1.8 seconds and 2.5 seconds for the 35th percentile of drivers.
• The average total stopping distance for a driver travelling at 80 km/h is 76.3 metres or 90.9 metres for the 35th percentile of drivers.
Applying that analysis, the average driver would not have had sufficient time and distance to avoid the collision in the dark.
Opinion as to the Cause of Crash The crash investigator considered that the following factors likely contributed to the collision:
• The pedestrian's intoxication level likely affected her cognitive ability and decision-making processes.
• The pedestrian chose to walk on the road surface in dark, unlit conditions despite the road having wide, cleared shoulders and a nearby foot path.
• The pedestrian failed to perceive the approaching vehicles or take action to move from the
roadway.
I consider that the failure to provide a courtesy bus or other safe means of transport, and the failure to have the roadway and pathway lit, also likely contributed to the collision.
Reducing the risk The NT Government’s 2024-2028 Towards Zero Road Safety Action Plan identifies intoxicated pedestrians as vulnerable road users. According to the associated Discussion Paper, to drive improvement the Action Plan is founded by the Social Model and the Safe System Approach, as follows:6 The Social Model of Road Safety differs from the traditional approach to road safety, which tends to focus on engineering and enforcement measures to reduce the risk of crashes and injuries. The Social Model approach emphasises the importance of understanding human behaviour and the role of social factors in shaping road user behaviour and calls for a more holistic, multi-disciplinary approach to road safety involving collaboration across different sectors and levels of governance. The Social Model recognises that the whole community must take ownership of the Towards Zero Road Safety Action Plan vision to reduce the high levels of road trauma in the Northern Territory.
Moving towards the goal of reducing fatality and serious injury on Territory roads, requires collaboration and partnerships between all levels of government, industry partners, workplaces, road safety stakeholders and every member of the community. These partnerships and commitments play a critical role in delivering road safety benefits which can impact positively and quickly on the whole community.
….
The Towards Zero Road Safety Action Plan 2024-2028 will continue to adopt the Safe System approach to improving road safety. The Safe System approach is a holistic view of the road transport system, which recognises that if people make mistakes or poor choices which may lead to crashes, the system is protective enough to ensure those actions do not result in road trauma. The Safe System approach is built on the key principles of:
• People make predictable mistakes that can lead to road crashes.
• The human body has a limited physical ability to tolerate crash forces before harm occurs.
• A shared responsibility exists amongst those who plan, design, build, manage and use roads and vehicles to prevent crashes resulting in serious injury or death.
• All parts of the system must be strengthened to multiply their effects; and if one part fails, road users are still protected.
I consider that actions are available that, if taken, may reduce the risks of similar deaths in the future.
It was known that:
• The Gove Boat Club is 12kms from Nhulunbuy.
• The event was advertised with a likely patronage of over 200 persons.
• Many of those attending would be drinking alcohol.
• A considerable number of patrons would depart at closing time.
• Many of those departing at closing time would likely be affected by alcohol.
• Those affected by alcohol should not be driving.
• There were only two taxis available for transport (with likely substantial delays for those wanting a taxi).
6 Developing a new Towards Zero Road Safety Action Plan 2024-2028 Discussion Paper pp 9,10
• Patrons waiting or hoping for lifts may walk back towards Nhulunbuy in an effort to secure a lift.
• There was limited or no road and footpath lighting between the Gove Boat Club and Nhulunbuy.
These matters were known or ought to have been known by the Manager and the Gove Boat Club licensee. In response to some or all these matters (and possibly also in recognition of the convenience to her patrons) in preparation for the event, the Manager tried to mitigate the impact and inconvenience by securing a courtesy bus. She was unable to secure a bus but because there was no condition on the venues liquor licence specifying that a bus must be made available, the event was able to proceed.
The first recommendation fits in the Social Model approach. In my view, a condition on this venues Liquor Licence that a courtesy bus must be provided to patrons at closing time should be considered.
The second recommendation fits in the Safe System approach. As it is now known that patrons (including intoxicated patrons) may attempt to walk from the Gove Boat Club towards Nhulunbuy, there should be adequate street lighting to reduce the risk to those pedestrians and other road users.
A draft of these findings was sent to the following persons/agencies inviting them to consider, correct, contribute, or respond.
Ms M Garde, Executive Director Liquor, Racing and Gaming; Northern Territory Liquor Commission; Mr N Baulch and Ms E Reed, Gove Boat Club; Ms Petherick on behalf of Department of Logistics and Infrastructure (DLI) On 18 February 2025, Ms L McCormick, Chief Executive Officer, DLI, advised “this road is not managed by the NT Government, as it is held by RIO Tinto under their lease. The Department of Logistics and Infrastructure will provide technical advice to RIO Tinto as required and offers its support as needed in addressing the Coroner’s recommendation relating to adequate street lighting along this road. However, I ask that your findings are updated to reflect the ownership and management of the road in which this accident occurred.” DLI provided two contact details for RIO Tinto.
The draft findings were then sent to Ms S Price and Mr A Hoffman of RIO Tinto providing an opportunity for RIO Tinto to consider, correct, contribute, or respond. On 28 February 2025, S Price advised that “it is not clear that the responsibilities for maintenance of public roads are properly defined in the mining lease itself. However, we are comfortable with your department noting that, given RIO Tinto have played a role in providing maintenance over the road in question, it is appropriate to refer to them in this matter.” Conclusion This death is yet another life tragically lost to our roads. This death will have a lasting effect on her family, friends, the driver of the vehicle, and the first responders called to attend this terrible scene.
All selected photos and stills courtesy of Major Crash Investigators Decision not to hold an inquest Under section 16(1) of the Coroners Act 1993 I decided not to hold an inquest because the investigations into the death disclosed the time, place and cause of death and the relevant circumstances concerning the death. I do not consider that the holding of an inquest would elicit any information additional to that disclosed in the investigation to date. The circumstances do not require a mandatory inquest because: the deceased was not, immediately before death, a person held in care or custody; the death was not caused or contributed to by injuries sustained while the deceased was held in custody; and the identity of the deceased is known.
Recommendations I recommend to the Department of Tourism and Hospitality (responsible Liquor, Racing Gaming) and the Department of the Attorney-General (responsible for the Liquor Commission) that the appropriate body engages with the Gove Boat Club/Gove Yacht Club licensee and nominee, to amend the Liquor Licence 81401564, or enter into an enforceable undertaking, or take any other steps necessary, to ensure that a courtesy bus is made available to patrons at closing time. The precise terms of any such condition, undertaking, or other measures are to be determined considering the known risks and the intent of the Social Model approach in the 2024-2028 Towards Zero Road Safety Action Plan.
I recommend to the Department of Logistics and Infrastructure, that, together with RIO Tinto, they ensure that adequate street lighting be provided between the Gove Boat Club and Nhulunbuy to reduce the risk to pedestrians. The extent of the additional lighting is to be determined considering the known risks and the intent of the Safe System approach in the 2024-2028 Towards Zero Safety Action Plan.
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