Coroner's Finding: Ghanbarzadeh, Masoud

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 Masoud Ghanbarzadeh Find, pursuant to section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Masoud Ghanbarzadeh; b) Mr Ghanbarzadeh died as a result of injuries sustained in a motor vehicle crash; c) The cause of Mr Ghanbarzadeh’s death was blunt trauma of the chest; and d) Mr Ghanbarzadeh died on 22 January 2020 on the Brooker Highway, at Glenorchy, Tasmania.

1. In making the above findings I have had regard to the evidence gained in the comprehensive investigation into Mr Ghanbarzadeh’s death. The evidence includes:  Police Report of Death for the Coroner;  Affidavits confirming identity and life extinct;  Report – Office of the State Forensic Pathologist;  Report – Forensic Science Service Tasmania;  Electronic Patient Care Record – Ambulance Tasmania;  Affidavits – Transport Inspectors;  Affidavit of Thomas Charles Darke, sworn 12 February 2020;  Affidavit of Andrea Christine Hermanis, sworn 8 April 2020;  Affidavit of Gary John Bester, sworn 13 February 2020;  Affidavit of Antionette Michaela Dobra, sworn 13 February 2020;  Affidavit of Joan Anne DeBoer, sworn 28 January 2020;  Affidavit of Lee Andrew Rawson, sworn 22 January 2020;  Affidavit of Naomi Louise Sansom, sworn 8 April 2020;  Affidavits of attending and investigating police;  Collision Analysis Report – Tasmania Police – Southern District Crash Investigation Services;  Affidavit of Dr Mark McCoid, sworn 25 August 2020;  Medical records – Churchill Avenue Medical Centre;

 Medical records – Mental Health Services, Tasmania;  Crash records – intersection, Brooker Highway and Elwick Road;  Southern Road and Public Order Services – Blood Analysis Result – Leigh Andrew Rawson;  Report – Dr A J Bell – Medical Advisor to the Coronial Division;  Scene photographs; and  Forensic Evidence.

Background

2. Masoud Ghanbarzadeh, known as Matthew, was born in Iran on 15 November 1968. He was 51 years old when he died. He arrived in Australia as a refugee in 1991, having fled Iran due to war. He and his partner, Naomi Sansom, had three children together.

3. In 2016, Mr Ghanbarzadeh suffered a very badly broken ankle. The ankle fracture required multiple surgeries. It is apparent that Mr Ghanbarzadeh developed something in the nature of a “chronic pain outcome” and developed an addiction to prescription medication including MS Contin and tramadol.

4. There is evidence of him engaging in drug seeking behaviour following his fractured ankle.

5. Mr Ghanbarzadeh was evidently a long-term marijuana user.

6. It is also apparent from his medical records that Mr Ghanbarzadeh suffered from mental illness. He suffered schizophrenia and bipolar affective disorder, for which he was medicated. In recent years, Mr Ghanbarzadeh had been admitted as an inpatient at least once in relation to mental illness.

7. In 2017, Mr Ghanbarzadeh was involved in a car accident. He crashed into a road barrier. He was seen by witnesses to be “fitting”. Blood tests taken after the accident showed he had high amounts of tramadol in his body. After the accident, his license was suspended until it could be confirmed that he had gone 12 months without seizure.

8. In 2018, Mr Ghanbarzadeh had another car crash. This time he hit a parked car. Blood tests taken after that crash confirmed high levels of diazepam in his body.

9. In the immediate lead up to his death, Ms Sansom was dispensing his medication to him, as she did not trust him to self-manage. His prescribed medications were olanzapine (5mg, for schizo-affective disorder), diazepam (5mg, for sleeping and agitation), tramadol (200mg, for leg pain) and augmentin duo forte (for respiratory illness).

Circumstances of Death

10. Mr Ghanbarzadeh saw his usual GP, Dr Mark McCoid, on Monday, 20 January 2020. In his affidavit given to investigators, Dr McCoid described what happened: “I saw Masoud on Monday, 20 January 2020. He told me he was travelling to Melbourne for work and requested authority to have the pharmacy supply additional medications while he was away. On friendly questioning Masoud quoted an airline, flight number and time. I authorised additional medication release on this basis. I have since been advised by police that Masoud was never travelling and now understand that he was deceptive on that day”.1

11. Mr Ghanbarzadeh left Dr McCoid’s rooms and went to the Brighton Pharmacy where he collected prescribed medication consisting of lyrica, diazepam and tramadol.

12. Mr Ghanbarzadeh had an appointment with Dr McCoid on the day of his death, Wednesday, 22 January 2020. Dr McCoid said that Mr Ghanbarzadeh appeared normal and that he (Dr McCoid) saw “no signs of drowsiness or anything to suggest intoxication”.2 Mr Ghanbarzadeh’s appointment with Dr McCoid commenced at 9.28am and lasted approximately 15 minutes.

13. Mr Ghanbarzadeh’s movements for the next 45 or so minutes are not clear. However, I am satisfied that the driver of the red Holden Commodore Berlina sedan described by the witness, Mr Thomas Darke, as driving erratically - “all over the road” - heading north on the Brooker Highway near the intersection of the highway with Bowen Road was Mr Ghanbarzadeh. 3 Mr Darke was sufficiently concerned about Mr Ghanbarzadeh’s driving to telephone police. He also followed Mr Ghanbarzadeh with his hazard lights activated in an attempt to protect other road users from danger. His actions were commendable.

14. I am also satisfied that the vehicle described by Ms Andrea Hermanis as “weaving across its lane and over broken lane lines”4 and driving erratically whilst travelling north on the Brooker Highway, near Howard Road at about 10.30am was that driven by Mr Ghanbarzadeh.

15. As he continued north, alone in his Commodore, on the Brooker Highway, Mr Ghanbarzadeh reached the intersection of the Brooker Highway and Elwick Road. As he did so he failed to stop his car and ran into the rear of a white Toyota RAV, driven by Mr Leigh Rawson, which was stationary and facing a red light.

1 Affidavit of Mark H McCoid, sworn 25 August 2020, page 2 of 3.

2 Supra.

3 Affidavit of Thomas Charles Darke, sworn 12 February 2020, page 1 of 2.

4 Affidavit of Andrea Christine Hermanis, sworn 8 April 2020, page 1 of 2.

16. Mr Ghanbarzadeh hit Mr Rawson’s car so hard that it forced it into the intersection, narrowly avoiding vehicles travelling from east to west. Mr Rawson’s vehicle stopped in the intersection. Mr Ghanbarzadeh’s Commodore travelled a short distance after smashing into Mr Rawson’s vehicle before coming to rest over the pedestrian crossing on the southern side of the intersection of Elwick Road and the Brooker Highway. The airbags in the Commodore activated. Both vehicles were extensively damaged.

17. Emergency services – Police, Fire and Ambulance – were all quickly on the scene. The Brooker Highway was closed between Goodwood Road and Elwick Road while emergency medical treatment of Mr Ghanbarzadeh was undertaken. Unfortunately, he was unable to be resuscitated and died at the scene.

Investigation

18. Mr Rawson, who fortunately only suffered minor injuries, was taken to the Royal Hobart Hospital for treatment and to undergo a blood test. He was also interviewed by police.

The result of the blood test showed that Mr Rawson was not affected by alcohol or drugs at the time of the crash.5

19. Officers from Tasmania Police Southern Crash Investigation Services attended the scene and carried out a comprehensive investigation. The detailed report which resulted from that investigation has informed these findings.

20. Mr Ghanbarzad’s body was taken to the Royal Hobart Hospital. At the hospital, life was formally declared extinct and his body identified by Ms Sansom. An autopsy was then carried out by the State Forensic Pathologist, Dr Donald Ritchey. Dr Ritchey expressed the opinion, which I accept, that the cause of Mr Ghanbarzadeh’s death was blunt trauma sustained in a motor vehicle crash.6 He found severe traumatic injuries of the chest that included bilateral rib fractures of the second through eighth ribs, a transverse fracture of the sternum and laceration of the pericardial sac. There was significant, fatal damage to the heart which caused severe internal bleeding. Dr Ritchey thought, and I also accept, that the mechanism of Mr Ghanbarzadeh’s death was hypovolemic shock.

21. Samples taken at autopsy were subsequently analysed at the laboratory of Forensic Science Service Tasmania. Numerous prescription drugs, including diazepam, oxazepam, tramadol, and olanzapine, were detected. So too was THC, the active constituent of cannabis.7 The drugs detected were certain to have had a depressive impact upon his 5 Southern Road and Public Order Services, Blood Analysis Result, Leigh Andrew Rawson, dated 19 February 2020.

6 Affidavit, Donald MacGillivray Ritchey, sworn 30 April 2020, page 10 of 12.

7 Affidavit of Neil McLachlan-Troup, Forensic Science Service Tasmania, sworn 6 April 2020, page 1 of 7.

central nervous system. I am satisfied that their presence significantly contributed to the happening of the crash by impairing his capacity to safely drive a motor vehicle.

22. Both vehicles were inspected by Transport Inspectors. Nothing was found as a result of either inspection which could have caused or contributed to the happening of the crash.

I also note that the weather conditions were fine and the road in good condition.

23. Dr McCoid’s prescribing medication for Mr Ghanbarzadeh was reviewed at my request by Dr A J Bell, the Medical Advisor to the Coronial Division, because it was apparent that prescription drugs were a contributing factor to the happening of the crash. Dr Bell provided a report in which he said, inter alia, that Dr McCoid’s prescribing appeared sound.8 I accept Dr Bell’s opinion.

Conclusion

24. Mr Ghanbarzadeh died as a result of injuries sustained by him in a motor vehicle crash.

The crash happened when he drove his motor vehicle into the rear of a car stationary, and facing a red light at an intersection on the Brooker Highway. When the accident occurred, Mr Ghanbarzadeh’s ability to drive a motor vehicle was impaired by the ingestion by him of significant amounts of prescription drugs and cannabis. The driver of the other vehicle was in no way to blame. Likewise, no other person was in any way to blame for the happening of the accident. Road and weather conditions did not cause or contribute to the happening of the crash. Neither did any mechanical deficiency on the part of either vehicle involved.

Comments and Recommendations

25. I extend my appreciation to investigating officer, Constable Jared Gowen, for his investigation and report.

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

27. I convey my sincere condolences to the family and loved ones of Mr Ghanbarzadeh.

Dated 12 May 2021 at Hobart in the State of Tasmania.

Simon Cooper Coroner 8 Report, AJ Bell, 5 August 2020.