Coroner's Finding: Cuthbertson, Kevin Ross

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Rod Chandler, Coroner, having investigated the death of Kevin Ross Cuthbertson Find, pursuant to Section 28(1) of the Coroners Act 1995, that: a) The identity of the deceased is Kevin Ross Cuthbertson; b) Mr Cuthbertson was born in Launceston on 5 November 1937 and was aged 79 years; c) Mr Cuthbertson died on 3 July 2017 at Rosevale; and d) The cause of Mr Cuthbertson’s death was traumatic asphyxia due to a heavy weight on his chest.

Background Mr Cuthbertson had been married to Gwendoline Winifred Cuthbertson since 1961. They resided at Rosevale and had three children. They were the owners of a Hino campervan (registered no. FM7611) which they had planned to take on a trip to Western Australia leaving on 19 July 2017. During June 2017 Mr Cuthbertson began work on the vehicle to ensure that it was in a mechanically sound condition.

Circumstances Surrounding the Death At around 10.30am on 3 July 2017 Mr Cuthbertson left the house intending to do some work on the campervan. It was parked in an open shed behind the house. It was Mrs Cuthbertson’s understanding that her husband intended to do some work on its differential and tail shaft. Approximately half an hour later Mrs Cuthbertson went outside onto the porch. She looked towards the shed and could see a light shining under the van near its rear left wheels. However, she could not see her husband or hear any noise.

At lunch time Mrs Cuthbertson again went outside and walked towards the shed. She called out to her husband but there was no reply. She walked up to the campervan and could see her husband’s legs underneath its right hand side. She touched a leg and it was cold. She realised that her husband was deceased.

Mrs Cuthbertson promptly called emergency services and Ambulance Tasmania attended. A paramedic confirmed that Mr Cuthbertson was deceased.

Post-Mortem Examination This was carried out by pathologist, Dr Terence Brain. In his opinion the cause of Mr Cuthbertson’s death was traumatic asphyxia due to a heavy weight on his chest. I accept this opinion.

Investigation This was overseen by Senior Constable Eileen-Jane Greenland of Tasmania Police. It included the obtaining of witness statements and the inspection of the campervan by a transport inspector from the Department of State Growth. It shows:  Found in front of both rear wheels of the campervan were wooden chocks approximately 8cm thick. One end of each chock had been cut at an angle enabling them to each act as a ramp.

 There were no wooden chocks found either in front of or behind the campervan’s front wheels.

 The front wheels were sited about 30cm behind sections of compressed gravel suggesting that the campervan had moved backwards approximately 30cm.

 That the campervan’s tailshaft had been disconnected and its differential was lying across Mr Cuthbertson’s chest.

 The park brake to the campervan had been applied and was in proper working order at the time Mr Cuthbertson was working underneath the vehicle.

 The system operating the campervan’s park brake relied on a continuous connection of the rear wheels via the tailshaft to the transmission mounted brake. Disconnection of the tailshaft enables the rear wheels to move independently. Therefore in this instance the unbolting and disconnection of the tailshaft enabled the campervan to roll backwards and down the wooden ramps.

Findings, Comments and Recommendations The evidence makes it clear that Mr Cuthbertson’s death occurred in the course of him carrying out maintenance work upon the family campervan, specifically to its tailshaft and differential. It shows that to facilitate this work Mr Cuthbertson had elevated the rear of the vehicle using wooden chocks. The park brake had been engaged to hold the vehicle in position. Mr Cuthbertson then lay on his back under the rear of the vehicle and proceeded to disconnect the tailshaft. Once disconnected the vehicle’s park brake has become disengaged, enabling the vehicle to roll backwards and off the wooden chocks. This caused Mr Cuthbertson to become entrapped with the vehicle pinning the differential to his chest and preventing his escape.

This was an easily preventable death. It should serve as a warning to all ‘home mechanics’ of the need to have a full understanding of the task being undertaken, the risks associated with that task and the implementation of appropriate strategies to address those risks. In this case it seems clear that Mr Cuthbertson’s tragic death occurred because he did not appreciate that the vehicle’s park brake would become

ineffective once he disconnected the tailshaft and had hence not taken any steps to ensure that it remained stationary and elevated whilst he lay below it.

I have decided not to hold a public inquest into this death because my investigation has been sufficient to disclose the identity of the deceased, the date, place, cause of death, relevant circumstances concerning how his death occurred and the particulars needed to register his death under the Births, Deaths and Marriages Registration Act 1999. I do not consider that the holding of a public inquest would elicit any significant information further to that disclosed by the investigation conducted by me. The circumstances of the death do not require me to make any further comment or to make any recommendations.

I convey my sincere condolences to Mr Cuthbertson’s family and loved ones.

Dated: 15th day of May 2018 at Hobart in the State of Tasmania.

Rod Chandler Coroner