Coroner's Finding: Cashion, Dale John

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Simon Cooper, Coroner, having investigated the death of Dale John Cashion Find, pursuant to Section 28(1) of the Coroners Act 1995, that: a) The identity of the deceased is Dale John Cashion; b) Mr Cashion died as a result of being run over by a motor vehicle; c) The cause of Mr Cashion’s death was multiple severe crushing injuries; and d) Mr Cashion died on 28 September 2018 at the Royal Hobart Hospital, Hobart, Tasmania.

Introduction

1. In making the above findings I have had regard to the evidence gained in the comprehensive investigation into Mr Cashion’s death. The evidence includes:  Police Report of Death for the Coroner;  Royal Hobart Hospital Death Report to Coroner;  Affidavits confirming life extinct and identification;  An opinion of Dr Donald Ritchey, the forensic pathologist who conducted the autopsy;  The results of toxicological analysis of samples taken at autopsy;  Ambulance Tasmania Electronic Patient Care Report;  Medical records of Mr Cashion – Tasmanian Health Service;  Medical records of Mr Cashion – Dr Danny Rimmer;  Tasmania Police body worn camera footage;  The results of analysis of the blood sample taken from Ms Joanne Margaret Durkin;  Affidavit of Mrs Pamela Cashion, Mr Cashion’s wife;  Affidavit of Ms Angelique Rita Keil, witness;  Affidavit of Mr Samuel James Vella, witness;  Affidavit of Ms Jessie May Wheeler, witness;  Affidavit of Mr David Andrew Hawkridge, witness;  Affidavit of Ms Isabel Rose Barney, witness;

 Affidavit of Ms Tracy Hemmings, witness;  Affidavit of Ms Rosemary Louise Beardsley, witness;  CCTV footage – the Collegiate School;  Affidavit of Senior Constable Richard Keygan, Tasmania Police, Crash Investigator;  Affidavit of Sergeant Daryn Splann, Tasmania Police;  Affidavit of Luke Wilson (rank not identified), Tasmania Police;  Affidavit of Constable Jesse Barnard, Tasmania Police;  Affidavit of Robert Von Wald, Tasmania Police;  Affidavit and photographs, First Class Constable Lauren McMahon, Tasmania Police Forensic Services;  Affidavit and photographs, Senior Constable Paul Hyland, Tasmania Police, Forensic Services;  Plan of Davey Street, Hobart prepared by Senior Constable Keygan;  Affidavit of Mr Noel Clark, Transport Inspector;  Record of interview with Ms Joanne Margaret Durkin conducted on 12 October 2018; and  Tasmania Police Incident Report, 28 September 2018.

2. In addition, this finding was informed by my inspection of the area where Mr Cashion sustained his fatal injuries.

Background

3. Mr Cashion was 61 years of age and married to Pamela at the time of his death. Mr and Mrs Cashion had been married for 42 years and had two adult sons together. They had lived in Mangalore since their marriage in 1976. A highly skilled carpenter by trade with a very strong work ethic, Mr Cashion was retired.

4. Reportedly, in generally good physical health for most of his life, Mr Cashion was diagnosed with bowel cancer in 2015. He underwent surgery and chemotherapy. The surgery was successful but Mr Cashion found it necessary to use a colostomy bag and, as a consequence of his ill health, generally retired from work.

5. Because of his cancer, Mr Cashion was required to undergo regular six monthly blood tests and have check-ups with his general practitioner. Accordingly, he and Mrs Cashion would visit their general practitioner, Dr Danny Rimmer, approximately once a fortnight. Dr Rimmer had been Mr Cashion’s GP for in the order of 20 years or more.

6. Mr Cashion had a history of mental health difficulties including a diagnosis of schizophrenia in 2000, episodes of psychosis and depression in 2002 and ongoing depression from that time.

7. Medical records indicate Mr Cashion received treatment as an inpatient at the Royal Hobart Hospital’s Department of Psychiatric Medicine on three occasions: once in 2002 and twice in

8. Each admission was voluntary and the two admissions in 2016 associated with, amongst other things, significant suicidal ideation. The suicidal ideation articulated by Mr Cashion involved, on both occasions, plans to walk in front of a high-speed truck or car.

9. At the time of his death, he was prescribed antidepressant and antipsychotic medication to manage his mental health by Dr Rimmer. Mr Cashion saw Dr Rimmer at his surgery, 203 Macquarie Street, Hobart, on the day of his death. Dr Rimmer’s records indicate that Mr Cashion reported that he had fainted two days earlier.

10. I set out the relevant parts of Dr Rimmer’s note of the consultation:1 “Collapse with LOC [loss of consciousness] briefly after standing on Wed night.

No palp.

No cp No pre-syncope Room was hot +++ LOC only 1 – 3 seconds Alert and awake straightaway Check ECG – NAD [NAD is a recognised medical abbreviation meaning ‘no apparent disorder’] HS NAD SR [indicating no abnormality of heart sound or sinus rhythm] Chest clear all zones No postural hypotension Examination BP (Sitting): 128/78 1 Medical records, Medical on Macquarie, pages 1 and 2 of 114.

Pulse (Sitting): 72 Regular BP (Standing): 132/82 Pulse (Standing): 72 regular … Assessment Vasovagal faint Mood improving Much calmer Much quieter No suicidality Not as obsessive Pam reports Mildy [sic] downcast today Some rapport No aggression No overt paranoia Less obsessive r/v [review] weekly ongoing.”

10. After the consultation finished, Mr Cashion left Dr Rimmer’s room with his wife.

Circumstances of Death

11. CCTV footage taken from the Collegiate School shows Mr and Mrs Cashion at 9.26am leaving Dr Rimmer’s surgery in Macquarie Street. They are seen walking on the footpath of Macquarie Street to Molle Street before crossing to the southern side of Macquarie Street.

Mr and Mrs Cashion then walk up the hill, south on Molle Street towards that street’s intersection with Davey Street.

12. In the CCTV Mr Cashion appears to slow, walk to the gutter and possibly spit or cough something into the gutter. His actions take place behind his wife who appears unaware that he slowed down briefly. Mr Cashion can then be seen following his wife to Davey Street, before turning left (or east) in the direction of where their car was parked. He then walks out of view of the CCTV.

13. Davey Street at or near the intersection with Molle Street has a general northeast to southwest orientation. It is five lanes wide. Traffic only flows in a general southwest direction.

14. Car parking is permitted on the northern side of Davey Street (adjacent the Collegiate School swimming pool and opposite the entrance to Anglesea Barracks). Mr and Mrs Cashion had parked their car, a Mitsubishi ASX, in the sixth parking bay back from the intersection of Davey and Molle Streets. Vehicles were parked immediately in front and immediately behind the Cashion’s Mitsubishi.

15. Davey Street is sealed with bitumen, in good condition and has concrete gutters and a sealed footpath on both sides of the road. It has appropriate and clearly visible lane markings. The speed limit in that area is 50 km/h. There are two 50 km/h speed signs located approximately 500 metres northeast of the scene.

16. Traffic lights control the intersection of Davey and Molle Streets.

17. The evidence is that on the day in question, and the time of the incident, the weather was fine, the road dry and visibility not in any way impeded by weather. Perhaps obviously, at 9.30am in late September, it was fully daylight.2

18. As Mr and Mrs Cashion approached their car, Ms Joanne Durkin was driving her white 2005 Holden Viva sedan in a general southwest direction on Davey Street in the far right-hand lane.

She was the only person in her car.

19. Mr and Mrs Cashion were walking north east on the footpath on the northern side of Davey Street. Mrs Cashion unlocked the car using her central locking remote fob key. Mr Cashion walked in front of the Mitsubishi seemingly to allow him to get into the front passenger’s door.

The car was parked lawfully facing southwest and on the right side of the road meaning that the driver’s door was closest to the footpath and the passenger’s door closest to the righthand traffic bearing lane of Davey Street.

2 For the description of the road and general area, I have relied on the affidavit of Senior Constable Keygan, sworn 15 March 2019.

20. As Ms Durkin’s Holden approached Mr and Mrs Cashion’s Mitsubishi, Mr Cashion either fell, or threw himself, onto the roadway immediately in front of Ms Durkin’s car. The front right corner of her Holden struck Mr Cashion and he became lodged underneath it as he was pushed forward a distance of 7.1 metres.

21. As soon as Ms Durkin realised what had occurred she stopped, put her car into reverse and attempted to move it off Mr Cashion. However, her car would not move and Mr Cashion remained trapped under it.

22. Mr Cashion’s head and torso were underneath Ms Durkin’s vehicle. In a distressed state, bystanders helped her from her car. Mr Cashion was left under the car, in accordance with a direction given by Ambulance Tasmania call centre staff. He was there for a matter of minutes before the arrival of emergency services personnel.3

23. Police lifted the Holden off Mr Cashion, with the assistance of bystanders. Ambulance Tasmania paramedics performed emergency first aid and attempted to resuscitate Mr Cashion at the scene. He was then rushed to the Royal Hobart Hospital Emergency Department where he was admitted. Despite further attempts at resuscitation, he died shortly after his admission.4 Investigation

24. Mr Cashion’s body was formally identified5 and then transferred to the hospital mortuary. At the mortuary, experienced forensic pathologist, Dr Donald Ritchey MD, MSc, FRCPA, carried out an autopsy on Mr Cashion’s body.

25. Dr Ritchey found that Mr Cashion had suffered multiple traumatic injuries including, most relevantly, significant blunt trauma of his chest and abdomen, right arm, right leg and head.

Although he had a 10 cm skull laceration, Mr Cashion suffered no significant skull contusion, skull fracture or brain injury. Dr Ritchey expressed the opinion, which I accept, that the cause of Mr Cashion’s death was the multiple injuries he sustained when he was run over by the car.6

26. Samples taken at autopsy were subsequently analysed at the laboratory of Forensic Science Service Tasmania. No alcohol or illicit drugs were identified as being present in those samples.

3 The Ambulance arrived at 9.36am, three minutes after being dispatched – see Ambulance Tasmania Patient Care Report.

4 See affidavit of Dr Michelle Bowen, sworn 28 September 2018.

5 Affidavit of Constable Jesse Barnard, sworn 28 September 2018.

6 Affidavit of Donald MacGillivray Ritchey, sworn 14 November 2018, page 10 of 12.

Therapeutic levels of an antidepressant drug and diazepam, as well as a sub-therapeutic level of an antipsychotic drug, were found to have been present in those samples.7

27. Police carried out investigations contemporaneously. Ms Durkin was required to submit a sample of her blood for analysis. That sample returned a negative result for alcohol, illicit and prescription drugs.8

28. Her vehicle was impounded by police and examined by a Transport Inspector. The Transport Inspector provided a report9 after that inspection. He expressed the opinion that Ms Durkin’s vehicle was in a road worthy condition prior to the incident. I accept that opinion.

29. Ms Durkin was interviewed by police under caution on the day of the crash. That interview was recorded on police body camera. On 12 October 2018, she was again interviewed, again under caution at the Hobart Police Station. On both occasions, Ms Durkin cooperated fully with the police. Summarising her account of what occurred, Ms Durkin said that she had spent the night before the crash at the Whittle Ward with her mother who was terminally ill with cancer. She had slept the night before, although that sleep had been interrupted. Ms Durkin left the hospital to go and purchase the ingredients to make a smoothie for her mother in her hospital room. She went to her car, which had been parked in the Whittle Ward carpark overnight. She left the car park and pulled into the right-hand lane of Davey Street, accelerated and drove through the Barrack Street intersection with a green light.

30. In the right-hand lane of Davey Street, Ms Durkin drove towards the intersection of Molle Street. She saw Mr Cashion standing at the front left corner of the Mitsubishi. She described Mr Cashion looking at her. She slowed her vehicle slightly having identified that Mr Cashion was a potential hazard.

31. Ms Durkin then described seeing Mr Cashion move back towards the footpath out of sight.

She continued to drive along increasing her speed slightly. As she drew alongside the Mitsubishi, Ms Durkin saw that Mr Cashion had moved back to the front of that vehicle again.

She told police that he appeared to look at her, very briefly, and then appeared to look down at the right front of her vehicle. She described him as somewhat crouching down in front of his vehicle, stretching out his right arm and laying in front of her vehicle. She attempted to brake but it happened so quickly she was uncertain as to what effect, if any, her braking action had. Ms Durkin described her vehicle becoming ‘stuck’ on Mr Cashion. She started screaming (by now her car was at a standstill) and a man opened her door and helped her out of her car.

7 Affidavit of Neil McLachlan-Troup, Forensic Scientist, sworn 30 October 2018.

8 Certificate of Analysis of Blood Sample – 1804475, dated 29 October 2018.

9 Affidavit of Noel Clark, sworn 10 October 2018.

32. Ms Durkin told police she thought she was doing about 40 km/h at the time of the crash.

33. A number of witnesses were identified and interviewed by police. Mrs Cashion told police that she saw her husband walk to the front of the bonnet of the Mitsubishi and remembered saying to him ‘be careful darling’. She recalled that there were some cars around at the time but did not recall how busy the traffic was. She did not actually see her husband be hit by the car. She said:10 ‘I must have taken my eyes off him for a moment, as the next thing I was aware that I heard a bang, and I saw Dale being dragged by a car. I recall seeing his brown jumper, and him being pushed along the road, under the car. I was frozen and couldn’t move. The car stopped and the lady driver jumped out, went to the side of the road and just started screaming’.

34. Ms Angelique Keil was driving her car in one of the centrelines of Davey Street not far from Ms Durkin’s vehicle. She provided an affidavit to police in which she described seeing Mr Cashion by the side of the road. Ms Keil said:11 ‘The man was looking right at the white sedan and then suddenly he took a step and appeared to dive down in front of the white sedan. The male went facedown – I am not sure if he dove or tripped – it looked like he was on the ground before he was hit’.

35. The final eyewitness identified was Mr Sam Vella. He described seeing Mr Cashion appear to fall backwards onto the road in front of Ms Durkin’s car. Mr Vella expressed the view that he considered that Ms Durkin ‘should have been able to stop in time before hitting’ Mr Cashion.12

36. Several other people in the general area assisted police in relation to the investigation by providing affidavits. None of those other people actually saw Mr Cashion being hit although Mr David Hawkridge heard the crash occur and, along with others, saw the immediate aftermath. In addition, four of those people - Mr Hawkridge, Ms Isabel Barney, Ms Tracy Hemmings and Ms Rosemary Beardsley - all nurses - provided immediate medical assistance to Mr Cashion.

Police Crash Investigation

37. Specialist police crash investigators completed a survey of the crash scene and the general environment. That survey enabled a scaled drawing to be prepared. That scaled drawing has informed these findings.

10 Affidavit of Pamela May Cashion sworn 1 October 2018, page 3 of 3.

11 Affidavit of Angelique Rita Keil sworn 28 September 2018, page 1 of 2.

12 Affidavit of Samuel James Vella sworn 28 September 2018, page 2 of 2.

38. In addition, police crash investigators, using CCTV footage, were able to determine that the average speed of Ms Durkin’s vehicle, in the lead up to the crash, was 45 km/h at a point 50 metres prior to the crash scene. Using the same CCTV footage, crash investigators determined that the speed of Mr Vella’s vehicle, which was following Ms Durkin’s vehicle, was travelling at approximately 38 km/h (consistent with his own account in his affidavit).13

39. Calculations were also made in relation to her capacity to stop a vehicle and her perception reaction time. The investigators concluded, and I accept, that travelling south west on the dry section of road at a speed of approximately 45 km/h, Ms Durkin’s vehicle had a minimum distance of 11.3 metres to come to a complete stop.

40. The evidence from the crash investigator was that travelling at 45 km/h, Ms Durkin required a distance of at least 20.75 metres and up to 30 metres to bring her vehicle to a safe stop.

41. I accept the methodology and accuracy of the calculations in relation to the speed of Ms Durkin’s vehicle immediately prior to the crash, the distance required to bring her vehicle to a stop and the distance she actually had to bring her vehicle to a stop to avoid hitting Mr Cashion.14 Conclusion

42. I am satisfied that road conditions, weather and / or impaired visibility did not cause or contribute to the happening of the crash. I am also satisfied that at the time Ms Durkin’s vehicle struck Mr Cashion, she was travelling at a speed less than the posted speed limit, unaffected by either alcohol or drugs and driving a mechanically sound vehicle.

43. I am also satisfied that Ms Durkin did not have sufficient time to either avoid Mr Cashion or bring her vehicle to a halt. As such, I consider that Mr Vella was mistaken in relation to his assessment of Ms Durkin’s capacity to have avoided hitting Mr Cashion. It is inconsistent with the objective evidence of specialist crash investigators. I should say that I do not think that Mr Vella was attempting to mislead anyone; rather, his evidence is an illustration of the widely recognised unreliability, at times, of eyewitness evidence, particularly in relation to incidents that happen quickly and in moments of great stress.

13 Supra, page 1 of 2.

14 As to those calculations, see the affidavit of Senior Constable Richard Keygan sworn 15 March 2019, pages 3 to 6 of 6.

44. I am unable, on the evidence, to determine whether Mr Cashion fell or deliberately placed himself in the path of Ms Durkin’s vehicle. I note that he had a history of suicidal ideation, and that ideation relevantly included articulating a method of suicide by walking in front of a moving vehicle. I also note that Ms Durkin and Ms Keil both described actions on the part of Mr Cashion that could be interpreted as suggesting he deliberately placed himself on the roadway with a view to being struck by Ms Durkin’s vehicle. However, I also note that Mr Cashion had just left his doctor whom he had consulted about a loss of consciousness two days before. It is certainly possible that he ended up on the road, in front of Ms Durkin’s car, because of a loss of consciousness.

45. There is no evidence that enables me to determine, with a degree of certainty, whether Mr Cashion fell, or deliberately placed himself, into the path of Ms Durkin’s vehicle.

Comments and Recommendations

46. I wish to thank Senior Constable Richard Keygan for his very professional investigation and report.

47. The circumstances of Mr Cashion’s death are not such as to require me to make any comments or recommendations pursuant to Section 28 of the Coroners Act 1995.

48. I convey my sincere condolences to the family and loved ones of Mr Cashion.

Dated: 13 July 2020 at Hobart in the State of Tasmania.

Simon Cooper Coroner