Inquest into the death of Road Death 51 of 2024

IN THE CORONERS’ COURT OF THE NORTHERN TERRITORY Rel No: D0253/2024 Police No: 24 103907

CORONERS FINDINGS ROAD DEATH 51 OF 2024 Section 34 of the Coroners Act 1993 I, Elisabeth Armitage, Coroner, having investigated the death of a 59 YEAR OLD CAUCASIAN FEMALE and without holding an inquest, find that she was born on 19 March 1965 and that her death occurred on 19 October 2024, at Royal Darwin Hospital in the Northern Territory.

Introduction: These findings concern road death 51 of 2024.

This was a single vehicle head on crash. The 59 year old female driver had a mid-range level alcohol reading of 0.096% and also suffered from numerous medical conditions. She lost control of her vehicle and collided with a tree as she entered a driveway. She commented to paramedics that she was doing 50-60kph and had been “unable to slow down”. It is not known whether she lost control as a result of being affected by alcohol or whether she suffered a medical episode. She passed away four days later, in hospital, from the combined impact of her injuries and underlying medical conditions.

Her death is a tragedy for her family and friends who mourn her unexpected passing.

Cause of death: 1(a) Disease or condition leading directly to death: Complications of blunt force chest injuries (Clinically diagnosed Pseudomonas pneumonia) Reported single motor vehicle 1(b) Morbid conditions giving rise to the above cause: collision (driver) Decompensated liver cirrhosis 2 Other significant conditions contributing to death (alcohol-related) and chronic but not related to the condition causing death: obstructive pulmonary disease

Following an external examination on 21 October 2024, Forensic Pathologist, Dr Salona Roopan 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.

• Toxicological analysis of blood obtained from hospital on admission of the decedent blood alcohol concentration of 0.096% which indicates moderate alcohol intoxication though the clinical effects can differ from person to person and due to individual factors. At this level, alcohol could impair cognitive and motor functions.

• 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 single motor vehicle collision as a driver.

Past medical history Review of the Northern Territory electronic clinical case record and hospital file showed a past medical history of Child Pugh C liver cirrhosis secondary to alcohol, chronic obstructive pulmonary disease, colonic polyps, previous cholecystectomy of cholecystitis, and haemorrhoids.

Most recent admission on 15/10/2024 for motor vehicle collision with reported polytrauma consisting of bilateral rib fractures, pulmonary contusions, small right-sided pneumothorax and lumbar spine fracture as per medical records. She developed type 1 respiratory failure secondary to pulmonary contusions, pseudomonas pneumonia and acute renal failure during admission as per medical records. The pre-existing alcohol liver cirrhosis reportedly decompensated. She passed away on the 19/10/2024.

Multi-region CT scan performed on the 15/10/2024 conclusion findings: Fracture involving first lumbar vertebra with approximately 30% height loss and minor posterior cortical bulging. Non-displaced fractures of the right 5-6th ribs and left 5th ribs with small right-sided pneumothorax. Large volume ascites.

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

Background: This 59 year old driver had three adult children. She was a hard worker and had worked in several industries over her life, but had retired and was enjoying reading, music, animals, cooking, and art. Her various medical conditions were taking a toll, and she was noticed to be slowing down.

Circumstances: On Tuesday 15 October 2024, at about 4.10pm, she was driving a white 2006 Holden Barina sedan along Doris Road, Berry Springs, towards the Lakes Resort Caravan Park. On

approaching the front gate to the park, it appears that she struck a large landscaping rock with the front right hand side of her car, grazed a gate post to her left hand side and the collided head-on with a palm tree located on the left-hand side of the driveway. The force of the impact caused the driver and front passenger airbags to deploy. She was wearing her seat belt.

The park manager heard the crash and came to assist, as did a retired paramedic who was staying at the park.

Emergency services were called at 4.09pm with St John Paramedics arriving at 5.06pm.

She remained conscious and told one paramedic that she was travelling at 50-60 kph and had been “just unable to slow down”. She is reported to have been speaking in short sentences and denied a history of similar events. She was treated in-situ by attending St John Ambulance paramedics, before being transported to Royal Darwin Hospital for assessment arriving at Royal Darwin Hospital at 6.19pm.

Her detailed hospital medical records document her medical problems, progress and treatments which are summarised in the comments of the forensic pathologist. It was reported that she was drinking alcohol frequently despite her severe liver disease.

Her prognosis and treatment plan were discussed with her family and a decision was made to aim for comfort and dignity over invasive interventions.

Family members were at her bedside when she passed away on Saturday 19 October 2024 at 11.30am, in ICU at Royal Darwin Hospital.

Location and conditions: The entrance to the Lakes Resort Caravan Park is located at the Southern end of Doris Road, which terminates at the park's entrance. There is a long straight and flat section of road approximately 300m in length immediately preceding the park entrance.

The roadway is two lanes wide without any road markings, except for several roadside signs indicating the entrance to the park. The park entrance consists of a white, waist-high sliding gate, which was open, and a decorative boulder which serves to divide entering and exiting traffic. There is a speed limit sign, indicating "10" kph. The roadway was dry and was sealed with asphalt and was in good condition.

The crash occurred in the afternoon, with fine and clear weather conditions prevailing, and no impediments to visibility.

Vehicle: The vehicle was 2006 Holden Barina sedan bearing NT registration and was inspected on 28/10/2024 for compliance with roadworthiness standards. The vehicle's body sustained damage consistent with major frontal impact and minor left rear side swipe. All components tested appeared to be standard as manufactured. There were no faults identified that contributed to the crash.

Tests and/or Calculations Conducted: At the time of crash, it did not appear likely that the driver would pass away, and scene measurements were not taken. In any event, there were no skid friction marks on the roadway left by the vehicle which could have been used to help calculate speed. This appears consistent with her comments that she did not slow down.

Opinion as to the Cause of Crash:

It is the opinion of the Investigating Officer that there are two likely scenarios as to the cause of the crash.

1. Driver impairment due to intoxication, or

2. In light of her lengthy medical history, loss of vehicle control because of a medical episode just prior to the crash.

Both appear plausible but the circumstances make it difficult to determine if either scenario is more likely.

Decision not to hold an inquest: Pursuant to s 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 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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