Inquest into the death of Road Death 9 of 2024

IN THE CORONERS’ COURT OF THE NORTHERN TERRITORY Rel No: D0037/2024 Police No: 24 15434

CORONERS’ FINDINGS ROAD DEATH 9 OF 2024 Section 34 of the Coroners Act 1993 I, Elisabeth Armitage, Coroner, having investigated the death of a 47-year-old male and without holding an inquest, find that the deceased was born on 5 June 1976 and that his death occurred on 12 February 2024, at Bagot Road, Ludmilla in the Northern Territory.

Introduction 60 people lost their lives on Northern Territory roads in 2024 compared to a total of 31 lives lost in 2023. The Territory death rate on roads is the is by far the worst in the country and 2024 was the highest death toll of the past 10 years. The road death toll has been described as “disgraceful” and “outrageous” by Senior Police and former Ministers. In light of this terrible loss of life and consistent with my function to ensure the coronial system operates efficiently and my power to comment on public safety connected with a death, I have undertaken to publish anonymised findings concerning all the road deaths in 2024. It is hoped that by making findings about the circumstances of these deaths public, this will improve individual and agency awareness as to the causes of road fatalities, with the ultimate objective of saving lives and reducing the road death toll in the future.

The ‘Fatal 5’ factors which are considered to give rise to the greatest risk of road crash deaths are:

• Drink/drug driving

• Failure to wear a seatbelt

• Excessive speed

• Distraction (e.g. mobile phone use)

• Fatigue According to the 2024-2028 Towards Zero Road Safety Action Plan, drug driving is known to be an increasing road safety concern throughout Australia. There is a particularly strong association between drug use and crash involvement. Many drugs can affect the ability to drive safely, including illegal drugs, as well as legal drugs such as prescribed and over the counter medicine. Drugs that can affect driving include cannabis, amphetamines, benzodiazepines, hallucinogens, antihistamines, and opiates.

In this single vehicle crash which claimed one life, at least two of the Fatal 5 factors were present: drug driving (methylamphetamine, benzodiazepine, opioid analgesic and cannabinoid) and a failure to wear a seatbelt. It is likely speed was also a factor.

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 single motor vehicle collision (driver) 2 Other significant conditions contributing to death but not related to the condition causing death: Mixed substance use (methylamphetamine, flunitrazepam, morphine, delta-9tetrahydrocannabinol) Following an autopsy on 13 February 2024, the Forensic Pathologist, found:

• The decedent was a 47-year-old adult male with a background medical history of chronic back pain, opioid misuse, and anxiety disorder documented in the electronic health records.

• Post-mortem examination (external and CT scan examination) showed significant blunt force trauma particularly involving the torso (chest, abdomen and pelvis) and left femur.

• Post-mortem toxicological analysis showed the presence of multiple substances, including: o Methylamphetamine (stimulant drug).

o Flunitrazepam and its metabolite, 7-Aminoflunitrazepam (benzodiazepine).

o Morphine (opioid analgesic).

o Cannabinoid (delta-9-tetrahydrocannabinol) and its metabolite

• I have no reason to believe with the information available, findings made during external examination, and post-mortem CT scan of the body that the death was due to any other cause than injuries sustained during the reported motor vehicle collision whilst under the influence of intoxicating substances.

Some of the expected clinical effects of the mixed substance use include drowsiness, poor concentration, slower reaction times and impaired judgment, mood and coordination; these impairments will have an adverse effect on a person's driving ability.

Specimens were taken for toxicological analysis Results: Forensic Science Case Number: 2400860 Preserved peripheral blood Alcohol not detected Preserved peripheral blood Methylamphetamine 0.11 mg/L

Preserved peripheral blood Flunitrazepam 0.003 mg/L Preserved peripheral blood 7-Aminoflunitrazepam 0.023 mg/L Preserved peripheral blood Morphine 0.02 mg/L Preserved peripheral blood delta-9-tetrahydrocannabinol greater than 50 µg/L Preserved peripheral blood 11-nor-9-carboxy-delta-9-tetrahydrocannabinol detected Preserved peripheral blood Gamma-hydroxybutyrate not detected No other drugs listed in the Scope of Analysis were detected in the preserved peripheral blood Police investigation A coronial investigation by police found no suspicious circumstances surrounding this death.

Circumstances The 47-year-old male driver spent many years working throughout Queensland and the Northern Territory. However, following a fight, he received an injury to his arm which forced him to give up his career and he moved back to Darwin. He visited his mother every Wednesday. On his last visit his last words to her were, “I love you mum”.

At about 11.00pm on Monday, 12 February 2024, he was driving his 1994 Mitsubishi Express van inbound along Bagot Road. After passing the intersection with Fitzer Drive he lost control of the vehicle, entering an anticlockwise yaw. The van struck a tree just behind the driver's door with such force as to uproot the tree. The driver’s side metal paneling crumpled on impact. The vehicle continued to rotate and struck another tree, this time on the passenger's side.

Sometime during the crash event, the driver was ejected from the vehicle through the front windscreen and came to rest on the roadway. A large part of a tree fell and landed on him, pinning him to the ground.

There was an ear witness to the crash, and it was immediately reported to emergency services at 11.03pm. St John Ambulance paramedics arrived at the crash site at 11.12pm and commenced treatment. The driver went into cardiac arrest shortly afterwards and was pronounced deceased at 11.34pm.

The crash was on the eastern side of Bagot Road between Fitzer Drive and Bagot Community, Ludmilla. In that location Bagot Road consists of three inbound lanes and is straight and level. It is sealed with asphalt and was in good repair. The roadway was damp from recent rainfall, but it was not raining at the time of the crash. (It started raining again shortly after the crash occurred).

The 1994 Mitsubishi Express van was inspected on 28 October 2024 at the Police Compound for compliance with the requirements of the Motor Vehicle Act, including the roadworthiness standards contained in the Northern Territory Inspection Manual for Light Vehicles. No defects were found that could have been contributed to the cause of the crash.

The weather was inclement with recent rainfall and the road was damp. There was little natural light due to prevailing overcast conditions. There were streetlights situated in the centre median strip of Bagot Road in the vicinity of the crash which were working and illuminated.

Tests and/or Calculations Conducted Detectives from the Major Crash Investigation Unit were called on duty and attended the scene. It was documented by photographs only. There was a lack of scene evidence because of the heavy rain and speed calculations could not be conducted. The driver was not wearing a seatbelt at the time of the crash. The vehicle was registered. His driver’s licence was suspended between 13 December 2023 and 12 March 2024 due to demerit points. It is not known whether the driver was aware of this suspension, but due to this suspension he should not have been driving.

Selected photograph curtesy of Major Crash Investigations Unit Opinion as to the Cause of Crash It is the opinion of the investigating member that the causes of the crash included loss of vehicle control as a combined result of damp road conditions, driver impairment (drug driving), and excess speed for the conditions.

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 relevant 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 and the death was not caused or contributed to by injuries sustained while the deceased was held in custody. The identity of the deceased is known.