Coroner's Finding: MADDERN Raymond Oliver

CORONERS ACT, 2003 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 24th day of July 2015 the 1st day of October 2015 and the 4th day of August 2016, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Raymond Oliver Maddern.

The said Court finds that Raymond Oliver Maddern aged 90 years, late of 38 Barr Dickson Crescent, Happy Valley, South Australia died at Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia on the 31st day of August 2012 as a result of bronchopneumonia complicating blunt head and neck trauma and ischaemic and valvular heart disease. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Raymond Oliver Maddern died on 31 August 2012. He was aged 90 at the time of his death. The cause of death at autopsy was bronchopneumonia complicating blunt head and neck trauma and ischaemic and valvular heart disease1, and I so find.

2. Background and the events leading to Mr Maddern’s death 2.1. Mr Maddern was living independently with his wife at the time of his death. On Wednesday 29 August 2012 Mr Maddern attended at the Flinders Private Hospital to visit his wife who was at that time a patient at the hospital having recently had surgery.

2.2. Mr Maddern went to the hospital by taxi. He was expected by his wife and daughter, Ms Snel. They were in a coffee shop awaiting his arrival. Ms Snel went to the lobby 1 Exhibit C2a

of the hospital and awaited her father just outside the front doors of the Flinders Private Hospital.

2.3. While Ms Snel was waiting for her father to arrive by taxi as expected, she noted a taxi pull up in a No Standing Zone on the roadway outside the Flinders Private Hospital.

She assumed that the taxi did not contain her father because she did not think that would be where any taxi driver would stop to let her elderly father out2.

2.4. Unfortunately, this was indeed her father and the taxi had pulled up in a No Standing Zone opposite the Flinders Private Hospital. The Flinders Private Hospital entrance is actually elevated above the level of the adjoining roadway. There is a driveway and a turning circle immediately outside the entrance. It would have been possible for the taxi to have turned into the driveway of the Flinders Private Hospital and brought Ms Snel’s father up to the level of the ground floor of the hospital. This would have saved him the need to walk approximately 50 or 60 metres up a steep driveway to gain entrance to the hospital.

2.5. Seeing a person that she recognised as her father alighting from the taxi in what was clearly an awkward position, Ms Snel immediately walked down the driveway of the hospital with the intention of assisting her father. She said that she was intending to ‘give him a hand’ and she saw that as he stood outside the taxi on its far side from her3 Mr Maddern had his walking cane crooked over his arm and appeared to be doing something with his wallet. In all probability he was putting the change from his fare into his wallet. Ms Snel saw the taxi pull away. Her father appeared to be a bit startled and stepped back. He tripped backwards on the curb and fell down a drop into a commercial carpark adjacent to the roadway4. Mr Maddern hit his head on a car that was parked in the carpark and then fell between that car and the wall of the carpark.

2.6. Ms Snel said that there was a yellow line designating a No Standing area where the taxi had stopped5.

2 Transcript, page 29 3 In other words on the left hand side of the vehicle looking forwards 4 Transcript, page 25 5 Transcript, page 26

2.7. The taxi driver was a man called Karanjit Singh. At the time he was working for Suburban Taxis. He was called to give evidence and agreed that he had dropped Mr Maddern off at the point described by his daughter. He accepted that it was not a designated taxi drop off area6. He accepted that he could easily have turned into the Flinders Private Hospital driveway7. However he said that he stopped where he did because that was where Mr Maddern asked him to stop8. He did not attempt to persuade Mr Maddern to remain in the cab and be taken up to a safer designated parking area9.

2.8. As he was driving away he noted in his mirror that Mr Maddern had fallen over, however he did not stop and he did not return to assist Mr Maddern because he was ‘nervous’10.

2.9. After some prevarication Mr Singh acknowledged that he could have himself got out the taxi and assisted Mr Maddern to get out safely.

2.10. Mr Maddern died two days after this incident directly as a result of the injuries he received from falling after alighting from the taxi.

3. Conclusions 3.1. It is quite plain that Mr Maddern would not have died had he not been allowed to alight from the taxi at that inappropriate point unassisted. It would have been perfectly easy for Mr Singh to have taken him up to the appropriate turning area outside the entrance to the Flinders Private Hospital. That would have prevented Mr Maddern’s death.

3.2. This unhappy incident reflects very poorly on Mr Singh. I hope that this tragic episode will be a reminder to the taxi industry to take proper care of elderly people when they make use of the taxi service.

6 Transcript, page 42 7 Transcript, page 42 8 Transcript, page 42 9 Transcript, page 45 10 Transcript, page 95

4. Recommendations 4.1. I have no formal recommendation in this matter, but draw this finding to the attention of the Taxi Council of South Australia.

Key Words: Transport Industry In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 4th day of August, 2016.

State Coroner Inquest Number 17/2015 (1470/2012)