Coroner's Finding: GIBBONS Leith

CORONERS ACT, 1975 AS AMENDED SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 14th and 15th days of February and the 7th day of March 2002, before Wayne Chivell, a Coroner for the said State, concerning the death of Leith Gibbons.

I, the said Coroner, find that, Leith Gibbons aged 17 years, late of 12 Elgar Avenue, Ingle Farm, South Australia died at One Tree Hill Road, One Tree Hill, South Australia on the 23rd day of November 2000 as a result of incineration.

1. Introduction 1.1. Just before 2:13pm on 23 November 2000 a Holden Commodore sedan was being driven by the deceased, Leith Gibbons, in a southerly direction on One Tree Hill Road at One Tree Hill when it failed to negotiate a sweeping left-turn curve, left the road and collided with a tree on the western side of the road.

1.2. Constable Tossell from the Elizabeth Traffic Division of SA Police reported that the vehicle negotiated about three quarters of the curve and then, for no apparent reason, went straight ahead, leaving tyre marks on the road which indicated that the brakes had not been applied prior to the collision (T69).

1.3. Mr Brian Hughes, a retired police officer, came upon the scene of the accident at 2:13pm that day. He said that smoke and dust where still settling when he arrived

(T8).

1.4. Mr Hughes made his way to the Commodore and checked the driver. He could find no pulse or movement. He thought the driver was deceased (T9). Another witness,

Mr Steven Salisbury who arrived slightly later, thought that the driver may have still been alive (T60).

1.5. Mr Hughes telephoned ‘000’ on his mobile telephone and the Telstra account (Exhibit C11a) discloses that the call was made at 2:15pm.

1.6. Mr Hughes said that he initially asked for an ambulance to attend but, while still on the telephone to the operator, he noticed flaming liquid dripping on to the roadway from the left hand side of the vehicle, and so he also requested the presence of the fire brigade (T20).

1.7. Mr Hughes tried to put the fire out with water he was carrying, but was unsuccessful.

1.8. Police Communications records disclose that they were advised of the accident at 1416:52 hours.

1.9. Mr Salisbury telephoned the direct number for the One Tree Hill Country Fire Service (‘CFS’). I was told that such a telephone call sets off the audible alarm. A CFS volunteer, Mr Cozzitorto, attended the station and turned off the alarm at 2:18pm.

Records disclosed that the Metropolitan Fire Service also received a call at 1418:04 hours.

1.10. An ambulance was despatched from the Elizabeth station at 2:20pm hours, having been alerted by the police.

1.11. While all this was happening, desperate attempts were made to extricate Mr Gibbons from the vehicle which quickly became engulfed in flames. There is some dispute on the evidence as to who was involved in these rescue attempts. Mr Hughes told me that he and a young man who had arrived on the scene, Robert Joy, tried to pull the driver out (T13), and his evidence was supported by Mr Joy (T29) and Ms Jane Costa (T74). Ms Costa told me that the two men tried ‘desperately’ to extricate Mr Gibbons (Exhibit C15, p1). The only dissentient was Mr Salisbury, who said that he and Mr Joy were involved, and that Mr Hughes was not (T51). I do not think that this discrepancy is significant. I suspect that all three men were involved, at different stages of the process, in trying to extricate Mr Gibbons from the vehicle. I am sure that the urgency of the situation may have led to the discrepancy in Mr Salisbury’s memory.

1.12. Tragically, the attempts to extricate Mr Gibbons were in vain, and the men were forced back by the flames which quickly engulfed the vehicle.

1.13. Little more could be done until Mr Cozzitorto arrived at the scene at 2:24pm. He was alone in the CFS vehicle and proceeded to put the fire out by himself. By the time the ambulance and Constable Tossell arrived at the scene, at 2:34pm, the fire was completely extinguished (T67).

2. Cause of death 2.1. A post-mortem examination of the body of the deceased was performed by Dr J D Gilbert, Forensic Pathologist, on 24 November 2000 at the Forensic Science Centre, Divett Place, Adelaide. Dr Gilbert determined that the cause of death was incineration. He reported that, on external examination, the body was extensively burnt. Internally, a number of ante-mortem injuries were noted, including a fracture of the left ankle, and fractures of the right tibia and fibula.

2.2. Dr Gilbert commented: ‘1. No clearly lethal injuries attributable to the vehicle accident were identified at autopsy.

The presence of traces of soot in the airways and the finding of occasional fat emboli within the lungs was consistent with at least a brief period of survival after the fire began. The deceased may have been unable to exit the vehicle because of entrapment by the wreckage, the bilateral lower limb injuries and/or loss of consciousness due to head injury. Neuropathological examination showed evidence of cerebral contusions very likely to be associated with loss of consciousness after the impact. Death has been attributed to incineration.

2. Analysis of a specimen of blood obtained at autopsy reportedly showed a blood alcohol concentration of nil and a carboxyhaemoglobin saturation of 3%. The latter finding excluded inhalation of products of combustion as a contributing factor in the death. No common drugs were detected in the blood.

3. No natural disease that could have caused or contributed to the death was identified at autopsy.’ (Exhibit C2b, p4)

2.3. When he gave oral evidence, Dr Gilbert confirmed that, having regard to the severity of Mr Gibbons’ head injuries, he would have been unconscious immediately after the impact (T83). Dr Gilbert was unable to express a firm opinion as to how long he remained alive after the impact, but indicated it would only have been a short period, a matter of a few minutes or less (T85).

2.4. Both Mr Joy and Mr Salisbury said that they heard Mr Gibbons make a noise during their attempts to extricate him from the vehicle. Dr Gilbert expressed the opinion that Mr Gibbons may still have been breathing at that time and emitted the noise even though he was unconscious. Alternatively, even if he had stopped breathing, it was possible that the act of moving him may have caused air to have been expelled from his lungs through the vocal chords giving the impression that Mr Gibbons was still alive. This evidence does not assist towards the conclusion to whether Mr Gibbons was still alive at that time (T87).

3. Issues arising at the inquest 3.1. Cause of the accident As I have already said, Constable Tossell was unable to establish a reason why the vehicle driven by Mr Gibbons left the road and collided with a tree. There is some evidence from his father that Leith may have been fatigued at the time of the accident (Exhibit C10, p4). There is also evidence that Leith had an inclination to drive fast, and that he did not appear to accept the possible consequences of speeding (Exhibit C8, p3).

3.2. A mechanical examination of the vehicle after the accident did not disclose that there was any defect in the vehicle that may have contributed to the accident (Exhibit C9a, p6).

3.3. In all those circumstances, I am unable to make a clear finding as to the circumstances of the accident except to say that I agree with Mr Gibbons (snr) that fatigue and inattention were the most likely factors involved (Exhibit C10, p3).

3.4. Response times Mr Gibbons (snr) initially expressed concern that the time taken for the attendance of the CFS vehicle and the other emergency services (Exhibit C10, p4) was excessive.

However, an analysis of these response times indicates that following Mr Hughes’ ‘000’ call at 2:15pm and Mr Salisbury’s call soon after, Mr Cozzitorto, a volunteer, attended the One Tree Hill CFS Station at 2:18pm, a response time of less than three minutes. Mr Cozzitorto then took a further six minutes to make the necessary preparations and attend at the scene whereupon he single-handedly extinguished the fire. It seems to me that this is a commendable response time in the circumstances. It is difficult to see how it might have been humanly possible to attend more quickly,

and in any event, even if one or two minutes could have been shaved off the time, it seems unlikely that the outcome would have been different.

3.5. Rescue attempts In my view, the evidence also clearly demonstrates that the three people who attempted to extricate Mr Gibbons from the vehicle, namely Mr Hughes, Mr Joy and Mr Salisbury, did everything they could to rescue him. Their efforts were described as ‘desperate’ by Ms Costa, an independent witness, and Mr Salisbury told me that his hair was singed by the flames during the attempt (T61).

3.6. It was clear that the car had been engulfed in flames, there was fuel leaking on to the ground, and the risk of an explosion must have been apparent. In those circumstances, the three men attempted to extricate Mr Gibbons from the vehicle at considerable risk to their own safety, and in my view, should be commended for their efforts.

4. Recommendations 4.1. In view of the above findings, I have no recommendations to make pursuant to Section 25(2) of the Coroner's Act which might prevent a similar death in these circumstances. Clearly, the authorities are doing all in their power to reduce the road toll. There is nothing arising from this inquest that I can usefully add.

Key Words: Motor vehicle accident In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 7th day of March, 2002.

Coroner Inquest Number 5/2002 (3017/2000)