Inquest into the death of Road Death 25 of 2024

IN THE CORONERS’ COURT OF THE NORTHERN TERRITORY Rel No: D0137/2024 Police No: 24 53268

CORONERS FINDINGS ROAD DEATH 25 OF 2024 Section 34 of the Coroners Act 1993 I, Elisabeth Armitage, Coroner, having investigated the death of a 42 year old Aboriginal male and without holding an inquest, find that he was born on 1 August 1981 and that his death occurred on 29 May 2024, at Progress Drive, Nightcliff in the Northern Territory.

Introduction: 2024 was a particularly deadly year on Northern Territory roads with 60 deaths recorded.

The Northern Territory has the highest rate of road fatalities of any jurisdiction, and of these it also has the highest rate of pedestrian fatalities. In the Northern Territory pedestrian crashes account for 23.1% of road fatalities compared to 13.7% nationally. 1 One retrospective study of pedestrian road deaths in the Northern Territory revealed that between 2001 and 2020, 865 road fatalities were pedestrians, and of these 42 were recumbent (26% of all pedestrian deaths). Acute alcohol intoxication (on the part of the recumbent pedestrian) played a role in all of the cases. The majority of incidents occurred at night. The study revealed a very high incidence of recumbent pedestrian deaths in an Australian subpopulation related to acute alcohol intoxication, decreased visibility, and vulnerability because of their position on or proximate to a road.2 Another, more recent study, which considered the 10 year period from 2013-2023 (the Menzies pedestrian deaths study), identified data from police and hospital records which consistently showed that in the NT, pedestrians involved in crashes are predominantly middle aged Aboriginal or Torres Strait Islander men3 and more than half of pedestrians involved in fatal accidents are intoxicated.4 1 Clifford, S., Lee, K.K., Ramsamy, R., Christophersen, C., Lamba, T., Dadi, A., Canty, R., Wardle, F. & Wright, C.J.C. (2025). Pedestrian deaths and serious injuries in the Northern Territory. Darwin, Menzies School of Health Research.

2 Tiemensma M, Byard RW, A 20 Year Review of Recumbent Pedestrian fatalities (2001-2020), Am J Forensic Med Pathol. 2023 June 3 Clifford, S., Lee, K.K., Ramsamy, R., Christophersen, C., Lamba, T., Dadi, A., Canty, R., Wardle, F. & Wright, C.J.C. (2025). Pedestrian deaths and serious injuries in the Northern Territory. Darwin, Menzies School of Health Research, p 20.

4 Ibid. p 30.

This death occurred in a known pedestrian crash hotspot, as identified by the Menzies pedestrian deaths study. The authors noted that “these hotspots may be useful for identifying zones where prevention efforts could be prioritized.”5 The authors also noted that alcohol outlets play a critical role in facilitating the level of intoxication that placed people at risk, highlighting the need for greater accountability for businesses who contribute to high levels of intoxication. The authors specifically referred to the clusters of outlets at Nightcliff and Coconut Grove. The graph below correlates alcoholrelated crash spots and alcohol outlets.6 5 Ibid. pp15,16 6 Ibid. pp 33,34

The Menzies pedestrian deaths study included the following observations:7 The Menzies pedestrian deaths study included the following recommendation:8 7 Ibid p 35 8 Ibid. pp 40,41

These findings concern the death of a recumbent, intoxicated, Aboriginal male pedestrian outside Litchfield Court, Coconut Grove which is, according to the Menzies research, in an alcohol-related crash hotspot.

It was nighttime and the intoxicated, recumbent, Aboriginal male was wearing dark clothing.

A driver of a Toyota Hilux spotted him on the road and returned to the scene in an effort to get him to move and to alert any other approaching vehicles to his presence.

Another vehicle, a Sonata, approached the recumbent male. The driver of the Toyota Hilux tried to alert the driver of the Sonata to the danger, by flashing his high beam and by tooting his horn.

Tragically these well intentioned efforts likely diverted the attention of the driver of the Sonata away from the road in front of him. The driver of the Sonata did not identify the recumbent male on the road and struck him with his vehicle. Even then, he did not identify that he had struck a person. He believed he had struck a rock and drove away.

The next day the driver of the Sonata heard on the news that a person had been struck and killed. He then realised that he may have been responsible and turned himself in to the police.

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: Reported motor vehicle collision (Pedestrian) 1(c) Acute alcohol intoxication Other conditions present but not regarded (or provable) as contributing to death was: Cannabis consumption Following an autopsy on 31 May 2024, Forensic Pathologist, Dr Salona Roopan commented:

Circumstances surrounding death The decedent was a 42-year-old adult male who had reportedly been struck by a vehicle. A passer-by who had been driving on the road, had reportedly stopped to render assistance.

Emergency services were contacted but the decedent was found to be in cardiac arrest.

Resuscitation was commenced and continued until 0024hrs when paramedics declared that the decedent had no signs of life.

Comments

• Post-mortem CT scan and external examination revealed significant blunt force injuries to the head, chest, pelvis and limbs. The abrasions on the back appeared patterned with linear areas of sparing.

• Toxicological analysis determined the blood alcohol level of the preserved femoral blood to be 0.22% which is associated with a clinical degree of moderate to severe level of alcohol intoxication. Although the clinical features of alcohol intoxication differs from person to person, a blood alcohol level of 0.22% can be associated with confusion and disorientation and is sufficient to significantly impair cognition, mood, judgement and co-ordination. A cannabinoid and its metabolite was also detected on toxicological analysis which is indicative of recent cannabis use.

• I have no reason to believe with the information available and findings made during external and radiological examination of the body that the death was due to any other cause than the injuries sustained during the motor vehicle collision reportedly as a pedestrian.

Background: The deceased male was born and raised in the Northern Territory. He had one child. He was proud of his work on his grandmother's country as a ranger in land management. But he also struggled with alcohol abuse and drug use. He was staying in Darwin and was on a Court Ordered Banned Drinker Order (BDO) when he passed away.

His family described him as a strong man who had a very close relationship with his family and country, and he showed great respect to his elders and countrymen.

He is greatly missed and mourned.

Circumstances: On Wednesday 29 May 2024 the deceased male was drinking with family members at a unit on Progress Drive, Coconut Grove. It is unknown where he sourced the alcohol or how much alcohol he consumed, however, he became highly intoxicated. At some stage of the night, he also consumed an amount of cannabis.

Prior to 11.45 pm he left the unit, saying that he was going to "get some breakfast and lay down on the footpath." A family member thought he was joking and did not follow up on the comments. She assumed that he intended on going to the local shops for some food which he was going to consume outside on the footpath.

The only CCTV camera that covers Progress Drive at that location was not working on the night of crash and there were no witnesses identified in the area at the time. It is not known if the male lay down across the inbound lane by mistake, thinking that it was the footpath, or if he stumbled off the curb and fell onto the road due to his intoxication. Regardless, he was

laying across the inbound lane, positioned with his head towards the centre of the lane. He was wearing a black shirt and dark coloured jeans.

At about 11.45 pm a Toyota Hilux was being driven inbound on Progress Drive towards Nightcliff. The driver of the Toyota Hilux later told police, "I was driving west on Progress Drive. It would have been about 11.45. Um, I saw a, uh, an Aboriginal man lying in the middle of the road, what appeared to have no shirt on and dark, dark jeans, like blue or black jeans on. Um, I've gone to the right side of the lane and gone around him." The Hilux driver drove down to the roundabout at Dick Ward Drive and turned around with the intention of returning and getting the male to move. He drove back towards where the male was lying. He stopped his Hilux in the outbound lane opposite to where the male was laying and yelled out to him, "look mate, get off the friggen road!" At the same time a taxi driver was driving his Toyota Camry taxi along Dickward Drive, towards the roundabout and turned right onto Progress Drive behind the Hilux. The taxi driver stopped behind the Hilux. The taxi had a low-resolution dash camera installed. The camera recorded the incident without sound. That footage is over-exposed, creating brighter than actual footage which does not accurately reflect the ambient light at the time.

At this time a Hyundai Sonata was being driven inbound towards Nightcliff with one passenger in the rear seat.

The Hilux driver saw the Sonata approaching and flashed his headlights repeatedly in an attempt to alert the Sonata driver to the presence of the male on the roadway. The Hilux driver was also yelling at the male to get off the road.

It is likely that the Hilux driver’s attempts to alert the Sonata driver to the male’s presence on the roadway had the opposite effect and distracted the Sonata driver’s attention away from where the male was lying and towards the Hilux. In addition, it is likely that the Hilux’s bright lights may have also ‘blinded’ the Sonata driver making it more difficult for him to see any impediments in his path.

At that moment the male began to sit up but he was struck by the Sonata. The male was knocked to the ground by the impact and then run over by the passenger side wheels of the vehicle. The impact caused the Sonata to bounce up significantly. The male was rotated counterclockwise in the crash event and came to rest lying along the curb of the inbound lane where he was likely difficult to see in the shadows. The crash was captured on the dash camera installed in the taxi.

The driver of the Sonata did not stop after the impact and continued to drive inbound towards Nightcliff. When he was later spoken to by police, in an Electronic Record of Interview, he said that he thought he had run over a rock in the road and his passenger had looked back and told him that he couldn't see anything on the road.

After the crash the driver of the Hilux called emergency services.

One of the male’s family members heard the crash and ran out. He found the male on the roadway unresponsive and thought that he was "already gone." Several other residents also attended the scene.

Police and St John paramedics attended.

Paramedics assessed the male and declared that he had passed away.

The attending police declared a crime scene and Investigators from the Major Crash Investigation Unit were called out. Major Crash members attended and photographed the male in situ before he was taken from the scene by Funeral Services.

A piece of the front grill of the Sonata was located at the scene and photographed. The piece was subsequently seized.

Major Crash members obtained photographs of the scene, and conducted a terrestrial survey captured by the unit’s Leica laser scanner.

In the meantime, the Sonata was driven to a street in Darwin City and parked. Police CCTV recorded the arrival as well as the driver and passenger inspecting the front passenger side of the Sonata using a torch. The driver later said that he saw some wires coming out at the front of the car on the left side.

At around 8.00 am the next day the driver called his wife who had been working all night.

His wife later told police, "Then I came this morning at home and my husband was not home cause he went to work, he goes to work early. Um, and then he called me at 8.00 am I think when he saw that news. And he's like, um, you know that, that thing last night, you know, um, I don't, I'm not sure if it's me. And then I said, why, why do you think it's you? And he said 'I was driving that road at 11.30 something like that time.” She said he told her "... I think I have to go to the police station. He said it right away and I said I just came from night, night shift. I said I'll just take a nap and you come from work and we'll go." At around 10.30 am the Sonata driver finished work and got home. His wife told police that she was "struggling to get up" due to being tired after her shift. After she woke up, at around 1.00 pm, the driver and his wife attended the Darwin Police Station.

The Sonata was seized and towed to the Forensic Sciences Branch at the Peter McAulay Centre for further analysis.

Scene and conditions: The collision occurred on Progress Drive outside Litchfield Court, Coconut Grove.

Progress Drive is a dual lane road. The road surface is sealed and in a good condition. The inbound and outbound lanes are divided by a solid white line. The posted speed limit is 60 km/h.

The crash occurred at nighttime with mechanical lighting in operation at the time. The weather was fine and clear.

Further investigations: The Sonata was forensically analysed at the location where it was parked and further analysed at Forensic Science Branch, Peter McAulay Centre (PMC). The Sonata was test driven and found to be in good working order with functional steering and braking. The vehicle’s headlights were functional. The mechanical condition of the vehicle is not considered causal to the crash and no further tests conducted.

Forensic Biology conducted analysis on several swabs taken from biological matter located on the Sonata. Biological matter from Marker Band E contained a DNA profile interpreted as coming from one individual. The DNA profile matched the profile of the deceased male.

No toxicology tests were conducted on the driver of the Hilux as he had only made himself known to Police outside of the 12-hour testing window.

Court proceedings: The Sonata driver was arrested and later charged with hit and run causing death. A trial was conducted from 1-5 September 2025, and he was found not guilty by a jury.

The Officer-in-Charge understood that it was likely that the jury were not satisfied beyond reasonable doubt that the Sonata driver saw the male lying on the road or that he knew that he had struck a person.

Opinion as to the cause of crash: The Officer-in-Charge considered that the collision occurred due to a combination of the males positioning on the roadway, his dark clothing and the actions of the Hilux driver in attempting to alert the Sonata driver to the male’s location.

Research shows that at night, a pedestrian in a recumbent/lying position on a roadway is more difficult to identify compared to a standing or walking pedestrian. Due to this, drivers take longer to identify recumbent shapes as a person/pedestrian, increasing the driver’s perception/response times. (Muttart, Bartlett, Kauderer, Johnston, & al., 2013) Additionally, the Hilux driver’s well-intentioned actions of flashing his high beams and honking his horn, likely diverted the Sonata driver’s attention away from the roadway in front of him and instead directed it towards the Hilux’s flashing lights on the other side of the road.

This distraction likely further impacted and delayed the Sonata driver’s capacity to identify that there was a male person lying on the road.

The glare of the Hilux’s high beam lights also likely reduced visibility of the male because of the contrast created between the bright light and the darker roadway.

Ultimately, considering all the circumstances, the crash was unavoidable by the average driver.

Conclusion: In the findings into Road Death 18 of 2024 I raised my concerns about the contribution a nearby liquor outlet may have played in the death an intoxicated female pedestrian who was walking on the road in the direction of her home.

In the findings into Road Death 41 of 2024 I raised my concerns about the contribution a nearby liquor outlet may have played in the death of an intoxicated female pedestrian who was crossing the highway.

In these findings, considering the evidence disclosed by the Menzies pedestrian deaths study, I am raising my concerns about the abundance of alcohol available at this known alcohol related crash hotspot. As the author of the Menzies pedestrian deaths study notes, “these hotspots may be useful for identifying zones where prevention efforts could be prioritised.”9 A draft of these findings, for consideration, contribution and/or comment was sent to:

1. Chief Executive Officer, Department of Logistics and Infrastructure

2. Licencing NT, Department of Industry Tourism and Trade

3. Officer in Charge of the coronial investigation, Detective Acting Seargent Adrian Prichard

4. Lead author of the Menzies pedestrian death study, Dr Sarah Clifford.

The Det A/Sgt Prichard and Dr Sarah Clifford confirmed they had no additional comments on the content of these findings. The CEO of DLI did not respond.

Mr Russell Goldflam, the Chairperson for the Northern Territory Liquor Commission, responded in the following terms and I have accepted his suggestion: 9 Ibid. p 15

“I note the comments and recommendations in the report drawn from the Menzies pedestrian deaths study, and specifically Recommendation 6 of the study, and the suggestion that trading hours in certain licensed premises could be reduced.

Section 113 of the Liquor Act 2019 confers on the Liquor Commission power to vary the conditions of a liquor licence on its own initiative. To date, the Commission has only ever exercised this power on receipt of a request from an agency, licensee, service provider or community organisation to do so. In exercising this power, the Commission can vary the trading hours of a licence.

The Commission is currently conducting inquiries pursuant to s 113 in Alice Springs and Palmerston. On 20 November 2025 it issued the attached Notice of Proposed Variation of Licence Conditions for various Alice Springs licensees. Among the conditions the Commission proposes to fix for certain licences, is this: Practices relating to disturbances The licensee must take reasonable steps –

(a) to prevent undue offence, annoyance, disturbance, noise or inconvenience to people who reside, work, study, worship or attend facilities that provide goods or services in the vicinity of the licensed premises, resulting from entertainment or activities on the licensed premises or the conduct of people making their way to or from the licensed premises; and

(b) to ensure public order and safety.

The Commission’s reasons for this proposed variation are set out at [74] to [81]. This proposed variation, if applied to licensees elsewhere, may go some way to addressing Recommendation 6 of the Menzies pedestrian deaths study.

Accordingly, I suggest that you consider amending the draft recommendation in the report to expressly refer to the Liquor Commission, which, in contrast to the Road Safety Taskforce and Implementation Project Team and the Director of Liquor Licensing, has the statutory authority to vary liquor licence conditions.” Recommendation:

1. I recommend to the Liquor Commission that it review this death with a view to determining what prevention steps can be taken to improve pedestrian safety at this alcohol-related crash hotspot, including but not limited to, considering the reduction of trading hours and/or the reduction of the number of liquor outlets to prevent/minimise the risk of intoxicated pedestrian road deaths.

Decision not to hold an inquest: Under section 16(1) of the Coroners Act 1993 (“the Act”) 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 and the circumstances do not require a mandatory inquest because: The deceased was not, immediately before death, a person held in care or o custody; and The death was not caused or contributed to by injuries sustained while the o deceased was held in custody; and The identity of the deceased is known.

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