Coroner's Finding: Crawford, Jacob Raymond

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 Jacob Raymond Crawford Find, pursuant to Section 28(1) of the Coroners Act 1995, that: a) The identity of the deceased is Jacob Raymond Crawford; b) Mr Crawford died as a result of injuries received in a quad bike roll-over; c) The cause of Mr Crawford’s death was head injury; and d) Mr Crawford died on 29 January 2019 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 Crawford’s death. The evidence includes:  Police Report of Death for the Coroner;  Ambulance Tasmania patient care report;  Royal Hobart Hospital Death Report to Coroner;  An opinion of Dr Donald Ritchey, the forensic pathologist who conducted the autopsy;  The results of toxicological analysis of ante mortem blood;  Affidavit of Ms Colleen Crawford;  Affidavit of Ms Hannah Devine;  Affidavit of Mr Regean Arnol;  Affidavit of Mr Ayden Harrex;  Affidavit of Senior Constable Richard Keygan;  Affidavit of Senior Constable Kelly Cordwell;  Affidavit (and photographs) of First Class Constable Dean Walker; and  Report from Mr Paul Wells, Transport Inspector.

Mr Crawford’s Background

2. Mr Crawford was born on 22 May 1983, the son of Scott Crawford and Jenny Lawrence.

At the time of his death he was 35 years of age, self-employed as a welder and fabricator and in a relationship with Ms Hannah Devine. He never married and had no children.

3. He was close to his family, in particular his older sister Bianca, half-sister Adele and stepmother Colleen. The death of his father in March 2018 hit Mr Crawford particularly hard.

4. It is evident that Mr Crawford was enthusiastic about motorsport, being involved in rallying, four wheel driving and drag racing. His stepmother said in her affidavit that he had been riding motorcycles since he was eight or nine years of age.1 He was experienced in riding both motorcycles and quad bikes.

Circumstances of Death

5. On Saturday, 19 January 2019 Mr Crawford attended an engagement party at the Richmond Golf Club. He went as a guest along with his girlfriend, Ms Devine. The party started at around midday and finished at about 10.00pm. The evidence is that Mr Crawford and Ms Devine arrived at the party later in the afternoon, between about 4.30pm and 5.00pm.

6. I am satisfied on the evidence that Mr Crawford drank alcohol at the engagement party.

The precise amount he drank is unclear. Ms Devine later told investigators2 that he had five or six 355 mL bottles of ‘Pure Blonde’ beer (which has an alcohol content of 4.6% by volume or 1.3 standard drinks per bottle).

7. The party finished and some of those in attendance left the golf club and went to a property at 772 Brinktop Road, Orielton for a so-called “after party”. Mr Jordan Headlam owned the property. Mr Crawford and Ms Devine arrived at the property sometime between 11.30pm and midnight.

8. At the “after party”, Mr Crawford consumed more alcohol. Again, the precise amount is unclear although Ms Devine later told investigators that she and Mr Crawford shared a pre-mixed vodka drink in a can.3 I will return to the issue of Mr Crawford’s alcohol consumption on that night later in this finding. However, the objective evidence in the form of analysis of blood samples taken after the crash suggest that Mr Crawford consumed considerably more than Ms Devine was aware.

1 Affidavit of Colleen Anne Crawford, sworn 17 May 2019, page 2.

2 Affidavit of Hannah Jean Devine, sworn 20 March 2019, page 2.

3 Supra.

9. Sometime after midnight, Mr Crawford and a number of other partygoers began to ride several quad bikes around the property.4 The number of quad bikes being ridden is also unclear. I am satisfied on the evidence of witnesses that it was between six and eight, with most, but probably not all, being ridden by a rider and carrying a pillion passenger.

Mr Crawford had Ms Devine as his pillion passenger. She was wearing a full-face helmet with a Perspex visor; Mr Crawford was wearing an open face helmet. The precise sequence of events is unclear but it seems that the various riders and their pillion passengers rode around tracks on the property in the dark. At various times riders stopped to allow riders and passengers to swap, thus enabling most people to have a turn riding. Witnesses later told investigators that everyone was riding slowly and sensibly. Reportedly, most riders were riding in groups and at times side-by-side so as they could talk to one another. I am satisfied that no one was riding especially dangerously or at an inappropriate speed.

10. Mr Crawford, who was not familiar with the property, essentially followed his friend Mr Arnol around. Like Mr Crawford, Mr Arnol also had a pillion passenger (also his girlfriend).

11. The property has a large dam. The dam is about two kilometres from the entrance to the property on the Brinktop Road. The dam has a raised dirt wall on its southern side.

On the top of the dam wall is a vehicle track that runs roughly north-south and is predominantly flat. At the northern end of the dam wall track the track falls into the dam’s overflow area, an area approximately six metres wide. The overflow area is full of dirt and rock. Beyond that area, to the north, is a steep incline (investigators later determined that the gradient of the incline was 29.7 degrees). A track runs up the incline in a northerly direction. It consists of hard soil, with large rocks embedded in the soil.5

12. Following Mr Arnol who had ascended the incline without incident, Mr Crawford rode the quad bike, with Ms Devine on the back, in a northerly direction along the dam wall, through the dam overflow area and up the incline. As the quad bike neared the top of the steep incline, it flipped over backwards. Ms Devine was thrown clear; Mr Crawford was not. The quad bike landed on his head and crushed his face.

13. Mr Arnol and Ms Devine tried to help Mr Crawford. Mr Crawford was still conscious and in great pain. An ambulance was called at 2.33am. Paramedics arrived at the scene at 2.50am and took over treatment of Mr Crawford. He was stabilised at the scene and 4 Affidavit of Hannah Jean Devine, sworn 20 March 2019, page 2.

5 See in particular survey prepared by Senior Constable Keygan, 31 January 2019.

then taken to the Royal Hobart Hospital where he was admitted just after 4.00am. At about the time of admission, blood was taken from him.

14. Despite extensive and appropriate medical treatment at the Royal Hobart Hospital, Mr Crawford did not recover from his injuries. At 1.30pm on Tuesday, 29 January 2019 he was declared brain-dead. In the Royal Hobart Hospital Death Report to Coroner the cause of death was recorded as “multifocal diffuse brain injury resulting in raised intracranial pressure leading to brain death”. As a consequence, and given the circumstances in which Mr Crawford sustained the injuries which caused his death, the fact of his death was reported in accordance with the requirements of the Coroners Act 1995.

Investigation

15. After Mr Crawford’s body was formally identified, it was transferred to the mortuary.6 At the mortuary an autopsy was performed by the then State Forensic Pathologist, Dr Christopher Lawrence. The autopsy confirmed the presence of a significant and extensive head injury with widespread damage to his brain and secondary brain swelling.

16. The blood samples taken when Mr Crawford was admitted to the hospital were analysed at the laboratory of Forensic Science Service Tasmania. That analysis indicated that at the time of his admission to hospital Mr Crawford had a blood alcohol level of 0.161g per 100 m/L of blood – over three times the legal alcohol driving limit. In a report7 provided as part of the investigation into Mr Crawford’s death, forensic scientist Mr Neil McLachlan-Troup said: “a blood alcohol concentration of 0.161 g per 100 mL alone has the potential to significantly impair driving performance and increase relative crash risk. It has been estimated that the relative risk of a driver with a blood alcohol concentration of between 0.14 g per 100 mL and 0.18 g per 100 mL being involved in a crash is approximately 20 to 50 times that of a driver with nil blood alcohol.”

17. The same analysis identified the presence of benzoylecgonine, the major metabolite of cocaine, in Mr Crawford’s blood at the time of his admission to the Royal Hobart Hospital. Mr McLachlan-Troup said, in the same report, that the identification of that substance “suggests that cocaine has been administered recently”.8 6 Affidavit of Constable Bowden, sworn 31 January 2019.

7 Rule 19 affidavit sworn 6 March 2019, page 1.

8 Supra, page 2.

18. I accept Mr McLachlan-Troup’s opinion as to the presence of alcohol in Mr Crawford’s body. I accept his evidence about the likely effects of that alcohol. I note that it is impossible for Mr Crawford to have consumed any alcohol between the quad bike crash and his admission to hospital. It follows that he must have had a high level of alcohol in his blood at the time of the crash and been significantly affected by it.

19. I also accept Mr McLachlan-Troup’s evidence as to the indicators of recent cocaine use. I conclude that Mr Crawford had used cocaine shortly before the happening of the crash in which he sustained his fatal injuries. Again, it is inconceivable that he used, or had administered to him, cocaine in the time between the quad bike crash and his admission to hospital.

20. The quad bike Mr Crawford and Ms Devine were riding at the time of the crash (a 2014 Honda TRX420TM1) was subsequently seized by police and inspected by a Transport Inspector who provided a report to me.9 The report indicates, and I accept, that the quad bike was appropriately maintained with only “minor damage evident consistent with impact”.10 The quad bike was not fitted with any type of roll-over protection device.

21. An inspection of the relevant owner’s manual indicates that it carries a clear warning to “never carry a passenger” noting that the quad bike is designed to be ridden by one person only. I accept that it is unlikely Mr Crawford looked at the owner’s manual before he commenced riding on 20 January 2019. However, I note that the quad bike carries a clear warning on the body of the bike, immediately under the left handlebar against carrying a passenger.11 The same warning also warns against the use of the quad bike after having consumed drugs or alcohol. I also note that the evidence is very clear that Mr Crawford was extremely experienced in relation to the use of quad bikes.12

22. The helmet, which Mr Crawford was wearing at the time of the crash, was taken with him to the Royal Hobart Hospital by Ambulance Tasmania. Unfortunately, the helmet was destroyed by the hospital prior to Mr Crawford’s death. Because police were not advised of the crash until after Mr Crawford’s death (and the matter obviously not reported to the coroner until then) the helmet was not available for inspection by investigators. The evidence suggests it is likely that the helmet had been purchased in Bali, Indonesia.13 While I accept that Mr Crawford was wearing a helmet, I am unable to make any finding as to whether it was compliant with relevant Australian Standards.

9 Report of Paul Ralph Wells, undated.

10 Supra, page 1.

11 See photograph 2510721_40. JPG 12 Affidavit of Colleen Anne Crawford, sworn 17 May 2019, page 2; affidavit of Hannah Jean Devine sworn 20 March 2019, page 1; affidavit of Ayden Bradley Harrex, sworn 15 March 2019 page 1.

13 See affidavit of Regean James Arnol, sworn 31 January 2019, page 1.

Conclusion

23. The evidence satisfies me that Mr Crawford died as the result of injuries sustained in a quad bike roll-over. The roll over occurred when Mr Crawford, affected by alcohol and with cocaine in his body, riding in the dark with a passenger (contrary to the clear warning displayed on the bike), flipped a quad bike as he ascended a steep, unfamiliar slope. I am unable to say whether the presence of any type of roll-over protection device would have altered the outcome. I am unable to say, on the evidence, whether the helmet Mr Crawford was wearing complied with the applicable Australian Standard.

If it did not, then it may have contributed to his death.

24. I am satisfied that his death was the result of an accident and that there are no suspicious circumstances surrounding it.

Comments and Recommendations

25. In August 2017, I handed down my findings after an inquest in relation to seven quad bike related deaths.14 In those findings, I commented and I repeat that, “no one should ever ride a quad bike whilst affected by alcohol”.

26. I extend my appreciation to investigating officer, Senior Constable Richard Keygan, for his investigation and report.

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

28. I convey my sincere condolences to the family and loved ones of Mr Crawford.

Dated: 15 June 2020 at Hobart Coroners Court in the State of Tasmania.

Simon Cooper Coroner 14 See Quad bike related deaths of Heather Dawn Richardson, Jan Severin Jensen, Kendall Russell Bonney, Vicki Mavis Percy, Jay Randall Forsyth, Jacob Graham Green and Roger Maxwell Larner (PDF File, 3.9 MB) 2017 TASCD 329 330 331 332 333 334 and 335