McDonald, Kerry-Ann

Introduction This is the inquest into the death of KERRY-ANN MCDONALD.

Jurisdiction Ms McDonald died on 22 October 2004 and therefore the relevant Act is the Coroners Act 2003 which commenced on 1 December 2003. I will refer to this Act at “the Act”.

The Act requires a coroner to investigate certain reportable deaths and sets out how coroners are to go about this task, including the holding of inquests and how they are to be carried out.

A Coroner’s Court is not bound by the rules of evidence but may inform itself in any way it considers appropriate.

Section 45(2) states that a coroner must find

• who the deceased was

• how, when and where the person died, and

• what caused their death.

Coroners are not to make findings that a person is either guilty of an offence or civilly liable but may make comments on ways to prevent deaths from happening in similar circumstances.

A written copy of my findings will be given to all parties represented at the inquest.

Evidence was given at Longreach on 3 and 4 May 2006 and at Emerald on 9 October 2006.

THE LEASE Ms McDonald died as a result of an incident on Mining Lease 95193 which is about 195 km south west of Winton on Mount Windsor Station. At the time of her death the Lease was in the name of Mayne River Gypsum Sales Pty Ltd and JOHN SULLIVAN was the Holder – according to the Mines Inspectorate.

However on 31 May 2000 Mayne River Gypsum Sales Pty Ltd entered into a written contract of sale with GEOFFREY IVAN COUPE and his wife BETTY MARLEEN COUPE to sell Mining Lease 95239 which in fact was an Application for a lease, not a granted lease. The only lease granted between 1 December 1995 and 22 October 2004 was Mining Lease 95193.

Mining Lease 95193 is actually contained within Mining Lease 95239.

So – on 22 October 2004 although, in practice, Mr Coupe was the Senior Site Executive, in control of the mine and in fact carrying on the activity on the lease, this was not reflected in the official records. On 24 October 2004 Mr Sullivan appointed Mr Coupe as Operator and Senior Site Executive. For our purposes, Mr Coupe was the operator and Mayne River Gypsum Sales (a partnership between Mr and Mrs Coupe) was the actual operator.

Mayne River Gypsum Sales carried on the business of quarrying gypsum on the lease, carting it to Winton for processing and then selling it for profit. I will refer generally to Mr Coupe rather than Mayne River Gypsum Sales for my own convenience.

THE LOADER The partnership owned the Kawasaki loader engine number “N E6-00615 OT” which was used on the lease to scrape up the gypsum into stock-piles and then load it into trailers. Various photos show the loader clearly.

The loader weights about 16 tonne unloaded and the bucket carries about 3 tonne making the total loaded weight about 19 tonne. It has good lighting to the front where all the work is done but relatively poor lighting to the rear.

The loader articulates in the middle i.e. it does not have a set of wheels which actually turn.

Appendix 7 to Exhibit 1 is an Accident Report Form concerning the loader prepared by Mr MIKE ROSS who at the time was a Senior Transport Inspector employed by Queensland Transport. Mr Ross also gave evidence.

Mr Ross said that the “mechanical condition of the loader was pretty good considering its age…it was in good nick mechanically”.

Mr Ross originally said that the reversing buzzer was not working but it was later found that one had never been fitted to the loader and Exhibit 9 is Mr Ross’ amended Accident Report Form.

The loader was not registered and was not required to be.

The loader is a big machine and the driver sits relatively high. There is a bucket at the front which is normally carried low to the ground as the higher it is the less stable the machine becomes.

The usual practice when loading on this mine site was to fill the bucket, reverse out with the bucket down low and as the loader approached the trailers in a forward movement, to raise the bucket to the appropriate height to unload it.

There are at least two (2) other obstructions/blind spots on this machine besides the bucket.

At the rear of the cabin there is a pillar which obstructs rear vision and then the engine cowling restricts normal rear vision to about 10 metres away, i.e. you cannot see the nearest 10 metres or so from the machine according to Mr Butterworth.

Mr McLellan said that because of the engine cowling “if you’re looking over the back of the loader, you would have been close enough to Ms McDonald where you would not have seen her from those rear lights.” and: “I think it would have been almost impossible to see Ms McDonald in terms of the way that loader had to go around that truck.”

THE TRUCK (PRIME MOVER) The vehicle which transported Mr SIMON GRAHAM BUTTERWORTH, Ms McDonald and her son MARVIN JAH MCDONALD GODINHO to the lease was a Kenworth Prime Mover owned by Mr Butterworth.

Mr Butterworth had been employed as a subcontractor by Mr Coupe for about two (2) months to, among other jobs, drive his own prime mover to the lease, load up with gypsum and bring it back to Winton for processing.

The prime mover had a sleeper cabin behind the driver’s cabin and various photographs clearly show details of the truck which had registered number 333-HBU.

The vehicle was registered but was not inspected by Queensland Transport after this incident as it was not relevant to the investigation.

Mr Coupe hired the prime mover from Mr Butterworth who used to submit invoices for this (see Appendix 12 for examples).

THE TRAILERS The prime mover was towing two (2) tipper trailers which were owned by Mayne River Gypsum Sales. Mr Butterworth towed the empty trailers from Winton to the lease with the intention of filling them and then returning to Winton.

BEFORE THE TRIP TO THE LEASE Mr Butterworth said he had known Ms McDonald for only a few weeks and about a week or so before the incident he had started to employ her to do his book keeping.

Ms McDonald had accompanied Mr Butterworth to the lease on two previous occasions. It had been arranged that Ms McDonald would accompany Mr Butterworth again on 22 October but her son Marvin apparently said he also wanted to go so the plans changed. In fact, Marvin said that his mother talked him into going – but this does not affect the outcome.

Mr Butterworth said he had tea at Tattersalls Hotel Winton at about 6:00 p.m. and that he had not drunk any alcohol that day at all – he only drank Coca Cola. This was supported by the publican, Mr Paul Neilsen and Marvin who said in his statement that he did not see Mr Butterworth drink any beer or alcohol, only Coca Cola.

He said he drove his truck to the Hotel and after tea he drove to Ms McDonald’s place and picked her and Marvin up. After that he drove to the BP Service Station where he happened to see and speak to Mr Coupe. Ms McDonald and Marvin got out of the truck and bought soft drinks and some food.

We do not know what was discussed between Mr Butterworth and Mr Coupe – but it is apparent that Mr Coupe knew that at least Marvin was accompanying Mr Butterworth to the lease. Mr Coupe said in evidence: “I had met Marvin that afternoon at 6:00 p.m. and I thought he’d have him in the cab of the loader – it’ll be alright and I didn’t take any action.” He also said: “I wasn’t aware that Marvin’s mother was also part of the story.” Ms McDonald had been drinking at the Gregory Hotel before she met up with Mr Butterworth and it seems that she took a 6 pack of VB cans and perhaps two (2) Rum & Cola cans with her in the truck. We do not know how many she consumed – Mr Butterworth took some empty cans out of the truck after he returned to Winton after the incident. Sgt Brayley said in evidence that he saw some empty VB cans in the truck and perhaps some full cans in a white plastic bag but he did not know how many. Mr Butterworth thought all the cans were empty.

The Autopsy Report showed that Ms McDonald had a blood alcohol reading of 0.086gm/100ml, i.e. .086%

THE TRIP OUT TO THE LEASE The prime mover, the two trailers, Mr Butterworth, Ms McDonald and Marvin left Winton at about 7:00 p.m. and travelled to Mt Windsor Station and the lease along the Winton Jundah Road before turning off that and proceeding along the mine access road for about 25-30 km before arriving at the lease at about 9:45 p.m.

Along the way they stopped once or twice to check the tyres and so on.

The trip was uneventful.

ARRIVAL The road train with its passengers arrived at the mine at about 2130-2145. It seems that Ms McDonald and perhaps Marvin were in the sleeper cab.

When they arrived Mr Butterworth parked the road train in a semi-circle to the right with the stock piles of gypsum on its right He checked the loader oil and water and then started the engine to let it build up air pressure and warm up. He then checked the road train tyres to see if he had any flat tyres. There were none.

He said that Marvin followed him around as he did these things.

When Mr Butterworth started driving the loader he had Marvin with him in the cabin of the loader and Ms McDonald was sitting in the driver’s seat of the truck watching proceedings. She had been told by Mr Butterworth to remain in the cabin during the loading operations. Marvin supported this. He said in his statement: “Before Simon got out of the truck I remember him saying to Mum “stay in the truck...” Mr Butterworth said that when Ms McDonald had accompanied him before (only a week or so previously) she had stayed in the truck and he had explained to her that if she wanted to get his attention she should stand on the truck fuel tank and he would see her. He said that on her first trip to the mine she had remained in the truck, both in the driver’s seat or the bunk and on the second trip she had started off with him in the loader and then transferred to the truck.

THE LOADING Mr Butterworth said he preferred to work at night because there were no tourists on the road, nights were cooler and therefore it was easier on machinery and there were no flies!

There were two (2) trailers to be loaded from the stock piles of gypsum. Mr Butterworth filled the rear trailer first, starting from the rear and loading from the driver’s side. The prime mover engine was running and the lights were on including head-lights, clearance lights and a light mounted on the mirror and another at the rear of the cabin which both shone towards the rear and lit up the trailers.

After filling the rear trailer Mr Butterworth commenced loading the front trailer from the driver’s side. He said he saw Ms McDonald sitting in the driver’s seat until the last couple of buckets when he noticed she was no longer there.

He assumed that she had climbed into the sleeper compartment so he kept loading from the driver’s side until that was completed.

He then got another bucket load of gypsum which he intended to take around to the passenger side to check on any spots which needed filling i.e. to fill any gaps in the loading which he had done from the driver’s side.

He drove the loader into a stock-pile and then reversed it out and kept reversing around the front of the prime mover. He passed through the lights on the front of the prime mover and passed about 2-2.5 metres from the front of the truck. He continued reversing around the truck and then more-or-less parallel to the truck and trailers as he checked the loading.

THE INCIDENT I will quote Mr Butterworth in relation to this: “While I was putting the last couple of bucketfuls in the front trailer, I noticed she wasn’t sitting in the driver’s seat any more, yet she’d been sitting there most of the time and then I grabbed another bucket to back round the other side – you just go along because sometimes when I’m loading I end up with a bit of a hole on the passenger side – sometimes in the middle, and just go round the passenger side and just top them up. It was when I backed it round that something just wasn’t right and I just stopped and she was in front of us.” It is apparent that she had been run over by the two (2) right wheels on the loader.

Marvin recalled it this way: “Simon…reversed back around the front of the truck…when he was doing this he was looking backwards and I was looking forwards. When the loader was next to the red truck, I looked down and saw Mum lying on the ground. She was yelling out. Simon got straight out of the loader and went to help mum. I heard mum yell out “reverse the loader”. At that time the loader was rolling slowly forward. Simon jumped back onto the steps of the loader and reached in. I don’t know what he touched but the loader stopped rolling.”

Mr Butterworth said that they talked about where it hurt and he then got a sheet out of the cabin, wrapped her legs in it and used both her belt and his to try and immobilize her legs.

During the interview with Mr McLellan on 12 January 2005 Mr Butterworth was asked: “Did you ask Kerry-Ann why she was out of the truck?” to which he replied: “Yes – that was when she said something about the stars but she was hard to understand.” Marvin said in his addendum statement, Exhibit 2: “After Simon had put Mum in the truck and he was driving out to the main road Mum told me that she was lying down looking at the stars and had fallen asleep. I don’t think Simon heard Mum say that because he was driving and I was looking after mum.”

AFTER THE INCIDENT Mr Butterworth said both he and Marvin attempted to establish communications on the truck’s UHF radio but to no avail. Eventually he and Ms McDonald, who never lost consciousness, decided that they had to leave the mine to endeavour to get medical assistance. He said he lifted the truck tool box out, lifted her into the truck, put the tool box back and then the three (3) of them left the mine.

About 1 km from the mine he was successful in reaching WAYNE MCCULLOCH at Warbreccan Station and told him of what had happened. He asked Mr McCulloch to advise Winton police. He also asked Mr McCulloch to try and get onto Mr RICHARD NEILSON of Elvo Station and seek help from him.

This conversation was overheard by Mrs SANDRA OATES at Jundah. After trying unsuccessfully to speak to Mr Butterworth or Mr McCulloch on the UHF radio, Mrs Oates tried to ring Mr Neilson at Elvo Station but was unsuccessful. She then tried Warbreccan Station but once again did not speak to anyone.

Mrs Oates then rang Jundah police and told Sgt ROSS STEVENSON what she knew. Apparently Sgt Stevenson and/or Mrs Oates (or both) rang Rockhampton

Communications Centre and in any event at about 0100 on Saturday 23 October 2004 Sgt Brayley, Officer in Charge, Winton Police and Senior Constable Jeremy Lambert received a call from Rockhampton Communications Centre.

Sgt Brayley then rang Mrs Oates and obtained further information from her. Winton police contacted the Queensland Ambulance Service at Winton, tried to find Mr Coupe and also the Winton Airport caretaker to get some portable lights to take with them to assist the Royal Flying Doctor Service aeroplane to land in the dark. They could find neither Mr Coupe nor the caretaker.

Mr Butterworth had meanwhile continued driving to the Winton-Jundah Road which he reached just after he observed no signs of life in Ms McDonald at about 0115.

At about 0145 Mr TROY HAMILTON arrived at the road junction. Mr Hamilton was driving a three trailer road train carrying cattle for Mt Windsor Station. Mr Hamilton saw a fire which Marvin had lit and Mr Butterworth’s road train stopped on the mine access road, the road Mr Hamilton intended driving down.

Mr Hamilton said he had heard Mr Butterworth calling on the UHF radio, trying to reach the police so he had some idea that something had happened. He stopped his road train on the Winton-Jundah Road and after speaking to Mr Butterworth he rang the police on his satellite telephone and passed the message that Ms McDonald had died. Mr Butterworth also spoke on the phone at that time.

Mr Hamilton said that he tried to comfort and assist Mr Butterworth and Marvin until Sgt Brayley and S/Const Lambert arrived at about 0430 with the ambulance.

Sgt Brayley said that when police arrived they found all three (3) people in distress, i.e. Mr Butterworth and Mr Hamilton and Marvin.

I will not continue on with what happened over the next hours and days but will turn now to factors which may have contributed to the incident.

ALCOHOL As I said before, Mr Butterworth had apparently not consumed any alcohol although Ms McDonald had. Her blood alcohol reading at the time of death was .086% and this was discussed with Dr Buxton, the pathologist. He said that the “peak” alcohol

would have been higher than that but it was impossible to “guesstimate” how much higher it would have been.

At .086% the law says that Ms McDonald should not drive a car but I think common sense would indicate that she was not under the influence of alcohol. Mr Butterworth did not believe she was.

LIGHTING There was a lot of evidence about lighting and a re-enactment was done but unfortunately the true lighting probably did not come through on the video and photos.

The only artificial lighting on the mine site was provided by the truck and trailers and the loader.

I mentioned lighting on the vehicles earlier but to reiterate, the loader was well lit at the front but not on the rear. The truck had four (4) headlights on, various clearance lights and two (2) other lights on the driver’s side, one (1) mounted on the mirror bracket and one (1) down lower on the rear of the sleeper cab, both facing the rear.

Mr Butterworth said that these rear-facing lights allowed good visibility along the truck and trailers. He described these lights as ‘loading lights’ – they allowed him to see the material in the back trailer and gave sufficient light to change tyres or cook a meal.

The truck also had four (4) spotlights but Mr Butterworth said these were definitely not on.

It can be seen therefore that there was good or at least adequate light on the driver’s side but the passenger side, where the last bucket was to be distributed, was not well lit.

There was also evidence concerning the amount of glare as you drove through the headlights and around to the passenger side. Mr Butterworth said that he sat above the truck headlights and they were not a problem whereas if the spotlights had been turned on they would have caused a problem.

Mr Bide asked Mr Butterworth: “Do the lights from anywhere when loading interfere with your vision?” and he replied “No”.

However there is no doubt that you would pass through an area of relatively high light intensity into an area of relatively low light intensity and it would take some time for your eyes to adjust.

DUST The loading and unloading of the bucket would seem to create a reasonable amount of ‘dust’ or fine powder in the air but Mr Butterworth did not see that as a problem, nor did he see any dust on the loader windscreens as a problem. He said he had in fact cleaned the loader windows with Windex only the night before and he could see well.

THE MANNER OF DRIVING In evidence Mr Butterworth said that as he came around the front of the truck: “I’m looking at the truck to make sure I’m not going to hit the truck as I come around the front of it…and as I’ve straightened up, I’m looking at the bins to see if they’re empty.” He told Mr Bide: “I was looking at the front of the truck and the bins, sort of everything…a couple of metres off the ground, not actually looking at the ground.” He told Sgt Brayley in the record of interview: “Just steady walking pace. Like It’s not quick. I’m just pretty big on like taking it easy. And like when you’re finished you just idle the machine back and just while your doing that last bit you just take it real slow and then when you’re done, like the machine’s not hot and you can just turn it off. You haven’t got to sit there and wait for it to idle down. And that was the thing we were just like a third throttle and just poking backwards. Like checking the bins and it was just a case I was checking the bins.” Marvin did not remark on the speed the loader travelled but he did say Mr Butterworth was looking “backwards”.

Mr Butterworth said that when he drove the loader he sat side on and used his left foot on the accelerator.

Mr Butterworth described how he loaded the trailers and drove the loader in general and particularly how he reversed around the front of the truck.

Inspector Fasching said that: “the way he was loading was not unusual for the industry.” Former Inspector McLellan said that the way Mr Butterworth used the loader was “very standard” and at page 129 of the transcript he said: “A loader will go to the other side of the truck to finalize loading. In this particular case he’s driven around the front of the truck. If you have a look at the position of the stock-pile to the front of the truck, the position coming back from that to load the off-side of the truck would be a normal thing to do because that’s the shortest distance.” Mr Coupe said at p.188: “My opinion of the way he reversed around the front of that prime mover would be exactly how I would do it…I would take the shortest route.”

THE LOCATION IN RELATION TO THE INJURIES The mine site is about 195 km from Winton which is a small town about 900 km west of Rockhampton and perhaps 600 km south-west from Townsville.

Mr Tate asked Dr Buxton if Ms McDonald’s injuries were so severe that death was inevitable to which he replied: “If this had occurred close to a major teaching centre where expert surgeons and everybody else on site ready to operate there would have been an outside chance they could have salvaged this poor lady If it had happened in Rockhampton or else in a small rural centre those injuries would have proven fatal.” The Autopsy Report, Exhibit 3, sets out the injuries more fully.

SECTION 48 OF THE CORONERS ACT 2003 Under the Coroners Act 1958 a coroner could commit a person to the Supreme Court or District Court in the same way as if a committal hearing had been held.

Under the present Act, if a coroner reasonably suspects a person has committed an offence, the coroner must give the information for an indictable offence to the Director of Public Prosecutions or for any other offences, to the Chief Executive Officer of the Department which administers the Act.

It seems to me that offences have been committed against the Mining and Quarrying Safety and Health Act 1999 and its Regulation 2001. However these are simple offences and have a maximum period of twelve (12) months to be commenced. The Department of Natural Resources and Energy Mining Inspectorate decided not to proceed with any charges and therefore that is the end of that.

However, there is a possibility that Mr Butterworth could be charged with dangerous driving causing death under Section 328A of the Criminal Code or perhaps manslaughter under the Criminal Code.

THE CRIMINAL CODE Section 291 of the Criminal Code provides that it is unlawful to kill another person unless that killing is authorized, justified or excused by law.

Section 293 provides that any person who causes the death of another is deemed to have killed that person.

Section 300 states that any person who unlawfully kills another person is guilty of the crime, which is called murder, or manslaughter, according to law.

Section 302 defines murder as an unlawful killing where the offender intends to kill or do grievous bodily harm.

Section 303 provides that any person who unlawfully kills another in circumstances which do not constitute murder is guilty of manslaughter.

There is no evidence at all which would indicate that Mr Butterworth intended to kill Ms McDonald or to do grievous bodily harm to her so I will only consider the offences of manslaughter or dangerous driving causing death.

Section 289 of the Criminal Code says as follows: “It is the duty of every person who has in the person’s charge or under the person’s control anything, whether living or inanimate, and whether moving or stationary, of such a nature that, in the absence of care or precaution in its use or management, the life, safety or health of any person may be endangered, to use reasonable care and take reasonable precautions to avoid such danger, and the person is held to have caused any consequences which result to the life or health of any person by reason of any omission to perform that duty.” Mr Butterworth was driving a 16 tonne loader with a bucket containing perhaps 3 tonne. There is no doubt in my mind that such a machine is dangerous and obviously it was because Ms McDonald died.

The questions are – did he use reasonable care and take reasonable precautions to avoid such danger?

At this point I will introduce Section 328A of the Criminal Code which at (4) states for our purposes: A person who operates a vehicle dangerous in any place and causes the death of another person commits a crime and is liable upon conviction upon indictment to imprisonment for seven (7) years.

It is self evident that this offence could also relate to Mr Butterworth The question is – does it?

The proper test to be applied to dangerous driving is the so-called objective test.1 1 R –v- McBride [1962] 2QB 167; [1961] 3 All ER 6

The objective test does not rely on the state of mind of the driver but is impersonal and universal.2 Dangerous driving does not require proof of criminal negligence.3 On a charge of dangerous driving, the test being objective, the degree of negligence is irrelevant. In R-v-Evans [1963) 1 QB 412; [1962] All ER 1086 it was held that if a driver in fact adopts a manner of driving which the jury thinks was dangerous in all the circumstances, then on the issue of guilt it matters not whether he was deliberately reckless, careless, momentarily inattentive or even doing his incompetent best. Such considerations are highly relevant for any person (Court) who has to consider whether a prosecution is justified or not.

In R-v- Gosney [1971] 2 QB 675 at 680 and 3 ALL ER 220 at 224 it was said that in order to justify a conviction there must be not only a situation which, viewed objectively, was dangerous, but there must also have been some fault on the part of the driver causing that situation. Fault involves a failure, a falling below the care or skill of a confident, experienced driver in relation to the manner of driving and the relevant circumstances of the case.

HINDSIGHT BIAS It is appropriate at this point to introduce the concept of hindsight bias, i.e. because we know the result we therefore consider, even unconsciously, a different answer to the question raised. For example in this case – we know Ms McDonald died so we may therefore, knowing that fact, look at the situation differently.

Inspectors McLellan and Fasching and Mr Coupe all agree that the method used by Mr Butterworth to load the trailers is very standard and at least probably if not absolutely the way they would do it – including the last load.

What may differ is the response to the situation where Mr Butterworth could no longer see Ms McDonald. We can all now say, knowing the result, that we would have stopped the loader and gone to see where she was. But would that have been our honest response at the time if we were driving the loader and an adult, who had been there before, who had previously been told to stay in the truck and had done so – including going out of sight into the sleeper cab – and on the night in question was told to “stay in the truck”?

2 R –v- Coventry [1938] 59 CLR 633 at 638 3 R –v- Wilson [1965] QWN 42

Would we have stopped and gone to check – or would we finish off the loading as Mr Butterworth intended to do?

Mr Butterworth said many times during his evidence words such as: “to my assumption she’d hopped into bed – she’d had a few drinks and it was getting late” and “At no time did I think she’d got out” and “Now if I would’ve had any doubt in my mind that she was out I would’ve stopped but there was no doubt in my mind” and “… Kerry’s not exactly a kid either – she’s got her own mind and she made the decision to get out” and “I’d asked her not to get out and she hadn’t previously, she stayed in the truck”.

I reiterate that under the Coroners Act 2003 I do not commit people but I give information to the Director of Public Prosecutions if I reasonably suspect a person has committed an indictable offence.

In this case I believe that the words on page 25 of Exhibit 1, the Report of Mr McLellan are correct when he said under the heading “Probable direct cause of the accident” “After being told to stay in the cabin of the prime mover by Mr Butterworth, Ms McDonald exited the cabin and inadvertently placed herself in a location where she could be struck by the operating loader”.

I will therefore not be forwarding any information to the Director of Public Prosecutions concerning criminal charges.

FINDINGS In accordance with Section 45(2) I make the following findings:

(a) the name of the deceased person is KERRY-ANN MCDONALD;

(b) she died as a result of being run over by a Kawasaki loader driven by SIMON GRAHAM BUTTERWORTH on Mining Lease 95193 at about 2220 on Friday 22 October 2004;

(c) she died at approximately 0115 on Saturday 23 October 2004;

(d) she died on the mine access road which links Mt Windsor Station to the Winton-Jundah Road, via Winton;

(e) she died as a result of multiple injuries as a consequence of motor vehicle trauma.

Section 46 of the Act allows the coroner to comment on various things, particularly ways to prevent deaths from happening in similar circumstances.

I believe this was a very rare way for a person to die – a “million-to-one chance” if you like.

During the course of the inquest such things as poor communication, allowing visitors on site and so on were raised and I believe that Mr Coupe and the Mines Inspectorate have already, since this tragedy, addressed all the recommendations which I could have made.

The Inquest is closed.

A G Kennedy Coroner 10 January 2006 Longreach