Date of death
2017-09
Finding date
2019-03-15
Cause of death
drowning
AI-generated summary
FW died by drowning in September 2017 at Bellerive, Tasmania, after entering the water from the Tasman Bridge. This case highlights systemic issues in public safety infrastructure and inter-agency coordination. While not a direct medical case, the coroner emphasizes the importance of rapid response systems for persons in crisis. The delayed implementation of live camera feeds to police dispatch represents a communication and system failure that could have assisted in timely location and potential rescue. Enhanced surveillance, live monitoring capabilities, and coordinated crisis response protocols are essential to prevent similar deaths. This case underscores the need for rapid escalation procedures and real-time communication between agencies when individuals are reported in potential crisis situations on high-risk locations.
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Error types
MAGISTRATES COURT of TASMANIA
CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 (These findings have been de-identified in relation to the names of the parties by direction of the Coroner) I, Olivia McTaggart, Coroner, having investigated the death of FW Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is FW; b) FW died in the circumstances described below; c) The cause of death was drowning; and d) FW died in September 2017 at Bellerive, in Tasmania.
[Paragraphs redacted] Comments I have noted in this finding the difficulty in the operation of the cameras [on the Tasman Bridge] in assisting to capture FW’s movements.
In my finding Deaths From A Public Place 2016 TASCD 385,386,387,388,389,390 I recommended that the Department of State Growth (“State Growth”) install additional and enhanced camera surveillance on the Tasman Bridge to provide improved quality footage and complete coverage of all pedestrian areas.
I have received information in this investigation that in October 2017, approximately one month after FW’s death, that State Growth installed new high-resolution cameras providing coverage of 99% of the Bridge with a 40-day recording capacity. The footage is monitored by State Growth for traffic control purposes and captures almost all pedestrian movements. This footage is able to be accessed by officers of Tasmania Police for investigation purposes. This access is provided by State Growth rather than a direct live feed into the Police Radio Room, as was the case with the previously installed (but inferior quality) cameras.
The Cross Agency Working Group (convened for the purposes of preventing suicide from the Tasman Bridge and to assist in implementing recommendations from the coronial finding) has been attempting to progress the issue of establishing a live feed
from the new cameras to the Police Radio Room. However, there has been a surprisingly lengthy delay in resolving the technological difficulties associated with implementation. This matter should be given priority. Timely access to the footage is vital in assisting police in locating, and saving, persons who have been reported as present on the bridge in a state of potential crisis. The evidence from the footage will also be invaluable for police and families in investigations of deaths and missing persons to provide information regarding that person’s movements.
Recommendations I recommend that the establishment of transmission of live footage from the Tasman Bridge cameras to the Police Radio Room be progressed with priority by the CrossAgency Working Group, Tasmania Police, and State Growth.
I recommend that State Growth ensure that the cameras installed upon the Tasman Bridge are subject to sufficient checks so as to ensure that they are operational and positioned to capture all pedestrian footways.
I recommend that Tasmania Police continue to ensure that all investigating officers are aware of the existence of the high-quality, full-coverage camera footage and the means to view and obtain this footage from State Growth for use in relevant investigations.
Conclusion I extend my appreciation to investigating officer Senior Constable Ann-Marie Pretyman for her most comprehensive investigation and report, as well as ongoing assistance.
I convey my sincere condolences to the family and loved ones of FW.
Dated: 15 March 2019 at Hobart Coroners Court in the State of Tasmania.
Olivia McTaggart Coroner
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