Inquest into the death of Road Deaths 33 and 34 of 2024

IN THE CORONERS’ COURT OF THE NORTHERN TERRITORY Rel No: A0030/2024

A0031/2024 Police No: 24 68289

CORONERS’ FINDINGS ROAD DEATHS 33 AND 34 OF 2024 Section 34 of the Coroners Act 1993 I, Elisabeth Armitage, Coroner, having investigated the deaths of a 17-YEAR-OLD ABORIGINAL MALE and a 64-YEAR-OLD ABORIGINAL FEMALE and without holding an inquest, find that the: Deceased Male was born on 13 March 2007 and his death occurred on 12 July 2024.

Deceased Female was born on 15 October 1959 and her death occurred on 12 July 2024.

Both their deaths occurred on 12 July 2024 at Tanami Road (27.8km West of Stuart Highway intersection) in the Northern Territory.

INTRODUCTION: 60 People lost their lives on Northern Territory roads in 2024. The highest road toll per capita in over a decade and by far the highest in the country. These findings concern road deaths 30 and 31.

In the Northern Territory 73% of fatal crashes occur on rural and remote roads. Of these, 47% are run-off/roll-over crashes. Aboriginal people are over-represented in the road toll. Although making up about 30% of the population Aboriginal people account for 50% of road fatalities and 30% of serious injuries. 33% of fatal crashes include the failure to wear seatbelts.

This was a double fatality crash involving a run-off/roll-over on a remote road. Both deceased were unrestrained (not wearing seatbelts) and were ejected from the Holden Commodore. The driver and front seat passenger were wearing seatbelts and they, together with the middle back seat passenger (who was not wearing a belt), survived the crash with minimal injuries.

The Holden Commodore was in an unroadworthy condition. Defect notices had not been attended to and it was unregistered and uninsured. The condition of the vehicle, particularly the poor condition of the unmatched tyres, contributed to this crash.

Additionally, the driver was unlicenced and had a significant history of traffic related offences. He was the regular driver of this vehicle and continued to drive it in an unroadworthy condition even after multiple police interventions. Furthermore, he had a history of carrying passengers who were not wearing seatbelts. Tragically for the family, on this occasion those choices contributed to a crash in which his 17-year-old son and another family member passed away.

The Deceased Male: 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 crash (passenger) 2 Other significant conditions contributing to death but not related to the condition causing death: Hyperosmolar hyperglycaemic state with renal impairment in the context of uncontrolled type 2 diabetes mellitus Following an autopsy on 22 July 2024, the Forensic Pathologist, Dr Salona Roopan commented: Comments

• The opinion as to the cause of death is based on the available police and medical information, and a full post-mortem examination including ancillaryinvestigations.

• The decedent was a 17-year-old male youth with background history of type 2 diabetes mellitus and complex social circumstances who was involved in a single motor vehicle collision. At autopsy, there was evidence of blunt force injury of the head (sliver subdural haemorrhage and focal subarachnoid haemorrhage), chest (rib fractures, bilateral small haemothoraces with descending aorta laceration), and abdomen (liver laceration, small haemoperitoneum and perinephric haemorrhage).

Biochemistry analysis showed a significantly high glucose level and high osmolality levels with evidence of renal impairment. The glucose level rapidly decreases due to continued cell metabolic processes even after death therefore the glucose level would have been considerably higher at the time of death because the post-mortem interval was 10 days.

• The blunt force injuries present in the decedent is most likely due to rapid acceleration- deceleration forces or direct trauma but invariably each of the injuries alone are not immediately fatal, however it would have also required emergency medical treatment. Small bilateral haemothoraces and small haemothoraces (combined internal blood loss of 360ml including mediastinal haemorrhage) indicate that the decedent demised rapidly after impact because rapid exsanguination would have resulted from the injuries to these highly vascularised structures (aorta and liver).

Although the blood loss is not considered sufficient to have resulted in hypovolaemic shock but the bleeding could have contributed to the traumatic shock state, especially when combined with the traumatic injuries.

• High glucose levels or hyperglycaemia, particularly at levels above 30 mmol/L, indicates poorly controlled diabetes, which can lead to osmotic diuresis, dehydration, and electrolyte imbalances. This hyperosmolar state could exacerbate the effects of even minor injuries, as dehydration can impair cerebral perfusion and healing. In addition, the injury and effects of the vehicle collision could have resulted in stress-induced hyperglycaemia which occurs in both diabetic and non-diabetic persons. Hyperglycaemia following trauma is a hypermetabolic response to stress which can be associated with a significant morbidity and mortality. But considering the decedents past medical history, it is highly likely that the

hyperglycaemia was primarily due to poor compliance and overall poor control of his diabetes.

• In this case, while the blunt force injuries present alone might not be immediately fatal, the significant hyperglycaemia suggests a more complicated picture with a complex interplay of trauma and pre-existing metabolic conditions.

• The combination of trauma and uncontrolled diabetes could precipitate a fatal hyperosmolar state or complicate what otherwise might have been potentially survivable injuries.

The Deceased Female: 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 crash (passenger) Following a CT scan Forensic Pathologist, Dr Salona Roopan commented: Comments

• This was the death of a 64-year-old adult female who was reportedly in a motor vehicle collision as apassenger.

• I have no reason to believe with the information available and findings made from postmortem CT scan of the body that the death was due to any other cause than the apparent motor vehicle collision as a passenger. Without autopsy examination, I am not able to fully define the nature of the injury or investigate the possibility of pre-existing natural disease

• In light of the information provided, I am of the opinion that a reasonable cause of death in the absence of an autopsy is: 1a. Multiple blunt force injuries 1b. Reported motor vehicle collision as a passenger Background: The deceased male was born at Alice Springs and grew up in Alice Springs, Yuendumu and Katherine. And had regular employment in a youth centre. He suffered with health issues most of his life with his main illness being Diabetes Type 1 & 2.

The deceased female was born at Coniston. She was mother to three boys and three girls, including one daughter who was a surviving passenger in the crash.

Circumstances: The day of the crash On Friday 12 July 2024, the driver, his wife, and their son (the deceased male) planned to travel in the family Holden Commodore to Yuendumu for a funeral. They were not planning to take anyone

else, but the deceased female rang and requested a lift for herself and her daughter, and this was agreed.

The driver was wearing his seat belt. His wife was the front passenger, and she was wearing her seat belt. The deceased female was the rear left passenger, and she was not wearing her seat belt. Her daughter was the rear centre passenger, and she was not wearing her seat belt. The deceased male was the rear right passenger, and he was not wearing his seat belt.

The driver did not ensure everyone was wearing their seat belts before he commenced driving towards Yuendumu.

The journey towards Yuendumu The Holden Commodore departed Warlpiri Camp, Alice Springs, and was recorded on CCTV turning left from Dalgety Road onto Stuart Highway northbound at 2:24:52pm.

At 2:25:53pm, it was captured by an ANPR camera approximately 1 km north of the MVR building on the Stuart Highway. Shortly after, at 2:26:32pm, it was recorded by Territory Traffic Surveys data site 4 km north of the MVR building, traveling at 95.36 km/h in an 80 km/h zone.

They stopped briefly at the Stuart Highway and Tanami Road intersection.

At 2:45:36pm, the vehicle was recorded 20km along Tanami Road, traveling at 114.60 km/h in a 110 km/h zone. This location is 3km from the crash site. The crash is estimated to have occurred between 2:45pm and 2:50pm.

The crash occurred on Tanami Road, Burt Plain approximately 23km west of the Stuart Highway intersection.

The Holden Commodore encroached onto the right (northern) roadway edge and dirt shoulder, where a significant height difference exists between the two surfaces. The jagged bitumen edge, uneven surfaces, and an unroadworthy right rear tyre caused tyre material to peel away, eventually leading to full tread delamination.

This resulted in the Holden Commodore veering left onto the roadway, depositing tyre debris, before the left front and rear wheels encroached onto the southern dirt shoulder. The vehicle then yawed right, crossing the roadway, entered the northern dirt shoulder, and became perpendicular to its travel direction.

The vehicle furrowed into long grass, struck undulations, and tipped passenger-side down before rolling multiple times.

During the rollover The left rear passenger (the deceased female) and right rear passenger (the deceased male) were ejected through their respective windows and thrown ahead of the vehicle's path. They both suffered injuries and passed away.

The vehicle passed through a large brush pile of tree branches and debris, before coming to rest just short of the ejected passengers.

At 2.50pm the Joint Emergency Service Communications Centre (JESCC) received a 000-call from the surviving rear seat passenger reporting the crash.

Police and St John paramedics arrived at the crash site at 3.25pm. The paramedics confirmed the male and female deceased and provided medical assistance to the other surviving persons from the crash. The surviving back seat passenger and the driver both reported a flat tyre in the lead up to the crash.

POLICE INVESTIGATION: Investigation, Tests and/or Calculations Conducted

The driver was Breath and Drug Tested and both results were negative.

A crime scene was established at 3:37pm covering approximately 400 metres in length and 50 metres in width. Officers from the Alice Springs Major Crash Investigation Unit attended.

At the eastern end of the scene, on the northern side of the roadway, strips of tyre material were found at the transition from bitumen to dirt. The first visible strip was marked with yellow paint and designated as evidence marker 61. This section of the bitumen roadway is elevated approximately 5cm above the surrounding dirt shoulder.

Police were able to identify the route the vehicle had travelled due to marks and the deposit of tyre material along the roadway.

A full length of delaminated tyre tread was found and marked with evidence marker 73.

The vehicle tipped onto its passenger's side and rolled several times. During the rollover, the rear drivers and passengers side occupants were ejected through their respective door windows and thrown in the vehicle's direction before hitting the ground. Both ejected passengers sustained injuries.

Additionally, during the rollover, the vehicle passed through a large brush pile of tree branches and plant debris before coming to rest just short of the ejected passengers.

An examination of the vehicle revealed extensive damage across its entire structure from rolling.

The original equipment (OE) wheel/ tyre size for the Holden Commodore was 205 / 55 R16. A check of the wheels and tyres revealed a mismatch of different branded wheel rims and tyres as follows: Location Tyre Size Rim Weight/ Speed Front Right 235 I 45 R17 97W Front Left 215 / 60 R16 95V Rear Right 205 I 65 R15 95H Rear Left 215 / 60 R16 99V

The rear drivers side tyre tread had completely delaminated, and one wheel nut was missing. This was consistent with the delaminated tyre material found at the start of the scene. The other three tyres were worn and had a below minimum tread depth.

Once the scene surveys were completed, the vehicle was towed to the Police Workshop Compound, Alice Springs.

The Crime Scene was closed at 1:30pm on 13 July 2024.

Road Features and Conditions At the crash site, the road ran in a Northwest/Southeast direction. The posted speed limit is 110 km/hr. The roadway was straight, sealed, dry and in good condition but lacked edge markings.

This section is a single lane road, averaging 3.3 metres in width. Due to its narrowness, vehicles must use the dirt shoulder to pass oncoming traffic safely.

The roadway is elevated approximately 5cm above the shoulder. The height disparity between the roadway and the shoulder is considered a contributing factor in the crash. Tyre material found at the scene suggests this height difference contributed to damage to the vehicles right rear tyre.

None of the survivors reported oncoming traffic as a factor.

Figure 24 - Pertinent locations along the route taken Weather and Lighting Conditions Bureau of Meteorology observations for the Alice Springs area indicate that at the time of the crash, the weather was dry, with a temperature of approximately 19.9°C, clear skies, and light winds.

Weather was not considered a contributing factor.

The crash occurred between 2.45 pm and 2.50 pm, well before sunset (6.04 pm) and last light (6.28 pm), under normal daylight conditions.

Lighting was not a contributing factor.

At the time, the vehicle was traveling at an average heading of 283°, while the sun's position was approximately 325° (Azimuth 145°). Given the sun's elevation, sun glare was not considered a factor.

None of the survivors reported sun glare as a factor in the crash.

Vehicle The vehicle was a 2002 Maroon Holden Commodore Sedan bearing NT registration plates.

Vehicle Inspection On 8 August 2024, a Transport Inspector from the Department of Infrastructure, Planning & Logistics (DIPL) inspected the vehicle at the Police Workshop Compound in Alice Springs. He completed his report on the 19 September 2024.

He identified multiple defects which made the Holden Commodore unroadworthy. Some of the defects were from the crash, but others were due to pre-existing wear or improper fitment. The Holden Commodore was unroadworthy before the crash.

Links between the vehicle and the driver Both the Holden Commodore and the driver were well known to the Police.

On 19 August 2022 Police conducted a vehicle stop on Holden Commodore XPG223 (SA plate fitted to the same vehicle prior to NT registration) on the Stuart Highway, Alice Springs. The driver was issued with a Notice to Appear for driving unlicenced.

On 29 September 2022 Police conducted a vehicle stop on Holden Commodore on Whittaker Street, Alice Springs. The driver was issued with a Notice to Appear for driving unlicenced, and for driving an uninsured and unregistered motor vehicle. The SA plates were seized as the driver was a Northern Territory resident.

On 18 November 2022 the Holden Commodore was registered with the Motor Vehicle Registry (MVR) and issued NT plates CE98LH under the name of the driver’s wife. The registration was valid for one month, expiring on 17 December 2022.

On 23 February 2023 Police conducted a vehicle stop on Holden Commodore on Woods Street, Braitling. The driver was issued with an Infringement Notice for driving an uninsured and unregistered motor vehicle and for having an unrestrained child in the car.

On 16 March 2023 Police conducted a vehicle stop on Holden Commodore on South Stuart Highway, Alice Springs. The driver was issued a Notice to Appear for driving an unsafe motor vehicle, driving unlicenced, and driving an unregistered and uninsured motor vehicle. He was issued a Defect Notice for no left-wing mirror, cracked windscreen and worn tyres.

On 18 April 2023 Police conducted a vehicle stop on Holden Commodore on Lindsay Street, Katherine. The driver was issued an Infringement Notice for driving an uninsured and unregistered motor vehicle, failing to produce a licence on request and driving an unsafe motor vehicle. He was issued a Defect Notice for no left-wing mirror, no petrol cap, cracked windscreen and worn tyres.

Both Defect Notices were still in force at the time of the crash. No attempt had been made to rectify the faults listed in the notices and no 'Defect Clearing Inspection' (which includes a full roadworthy inspection by a Transport Inspector) had been conducted.

Prosecution Having considered the evidence concerning the circumstances of this double fatality crash, the Director of Public Prosecutions (DPP) recommended that there was sufficient evidence to charge the driver with Section 30B offences under the Traffic Act 1987 (careless driving resulting in the death of a person) but there was insufficient evidence to support charges under Section 174F under the Criminal Code Act 1983 (dangerous driving causing death).

On the 30 December 2024 the driver was arrested for the following offences:

• Careless Driving Causing the Death of the deceased female

• Careless Driving Causing the Death of the deceased male

• Driving a Motor Vehicle While Unlicensed

• Driving a Motor Vehicle Unsafe to Drive

• Driving an Uninsured Motor Vehicle

• Driving an Unregistered Motor Vehicle

• Driver Did Not Ensure 16+ Passenger Wears Seatbelt - the deceased female

• Driver Did Not Ensure 16+ Passenger Wears Seatbelt - the deceased male

• Driver Did Not Ensure 16+ Passenger Wears Seatbelt - the backseat survivor The driver was granted bail and was scheduled to appear at the Alice Springs Local Court on 6 February 2025.

The prosecution file was submitted to the Alice Springs Prosecution Adjudication Unit on the 30 December 2024 for the complaint charges to be laid before the statute of limitations passed on 11 January 2025.

Due to an administrative error between the Police computer system SerPro and the Court computer system IJIS, the cut-off date was missed. The charges were laid on 6 February 2025, out-of-time, and so they were dismissed.

Police have advised that steps have been taken to ensure this SerPro administrative error does not occur again.

Opinion as to the Cause of Crash: It was the Crash Investigators opinion that the Holden Commodore veered off the narrow roadway, resulting in the delamination of the rear driver's side tyre, which was already unroadworthy.

The combination of the defective tyre, narrow roadway and lack of seatbelt use directly contributed to the fatal crash.

The driver was unlicenced and should not have been driving.

The driver had never held a valid driver's licence and had significant history of traffic-related offences, including: 19 x Drive Motor Vehicle While Unlicenced 5 x Drive Motor Vehicle While Disqualified 9 x Drive Motor Vehicle with an Unrestrained Child 3 x Drive Motor Vehicle Unsafe to Drive 9 x Drive Uninsured Motor Vehicle 9 x Drive Unregistered Motor Vehicle The Holden Commodore was uninsured, unregistered, and in an unroadworthy condition and should not have been on the road.

The speed driven was either at the posted limit or slightly above. While not excessively above the posted limit, the speed could become a crucial factor if an unroadworthy vehicle component fails, such as a flat tyre. Even minor failures in unroadworthy components can escalate into more severe consequences at higher speeds.

All selected photos and diagrams 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 deaths disclosed the time, place and cause of each death and the relevant circumstances concerning the deaths. 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 persons were not, immediately before death, persons held in care or custody; and the deaths were not caused or contributed to by injuries sustained during custody; and the identity of the deceased persons is known.