Coroner's Finding: Greene, Yvonne Beverley

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Olivia McTaggart, Coroner, having investigated the death of Yvonne Beverley Greene, Find, pursuant to Section 28(1) of the Coroners Act 1995, that: a) The identity of the deceased is Yvonne Beverley Greene; b) Mrs Greene died in the circumstances set out in this finding; c) The cause of death was head injuries suffered in a fall; and d) Mrs Greene died on 5 July 2019 at Stanley, Tasmania.

In making the above findings I have had regard to the evidence gained in the comprehensive investigation into the death of Mrs Greene. The evidence includes:  The Police Report of Death;  Affidavits of life extinct and identification;  Opinion of the pathologist regarding cause of death, including pacemaker analysis;  Toxicology report regarding analysis of Mrs Greene’s blood sample;  General practitioner records from Smithton Medical Centre;  Affidavit of Mrs Greene’s husband, Ross Greene;  Affidavits of Mrs Greene’s son-in-law, Craig Blizzard;  Affidavit of Julian Jacobs, manager of the Stanley Hotel;  Affidavit of the investigating police officer;  Report of Circular Head Council;  Report of Consumer Building and Occupational Services; and  Report from Ambulance Tasmania regarding attendances at the Stanley Hotel.

Yvonne Beverley Greene was born Yvonne Beverley Carol on 15 February 1946 in New South Wales. At the time of her death she was aged 73 years and lived with her husband, Ross, at Christmas Hills, Tasmania.

Mrs Greene worked in customer service at retail outlets and managed her own fabric shop until she retired. Mr and Mrs Greene have four adult children.

Mrs Greene was diagnosed with hypertension in 2005 and dilated cardiomyopathy (large, diseased heart) in 2018. She suffered the usual symptoms relating to cardiac illness and, in February 2019, she had a pacemaker and defibrillator inserted at the Austin Hospital, Melbourne. Subsequently, she reported an improvement in her energy levels and health. She was under the ongoing care of her cardiologist and general practitioner.

Circumstances of Death On 5 July 2019, at 7.00pm, Mrs Greene and her husband attended the Stanley Hotel to celebrate their 50th wedding anniversary. They were with family members and friends. They enjoyed a meal at the hotel. At about 9.30pm, when they were ready to leave, they made their way to the rear exit door of the restaurant, intending to walk down the external stairs leading to the car park. Mrs Greene was following her son-in-law, stepping slowly and sideways on the building side of the stairs. There were ten stairs in total with an overall rise of about 1.5 metres.

When she had walked down about three stairs she began to fall and hit the ground at the bottom, landing head first. Mr Greene said that she seemed to misplace her foot on the step before falling. Ambulance Tasmania personnel were called and attended, however Mrs Greene had, sadly, passed away.

Mrs Greene was transported to the Launceston General Hospital’s mortuary where pathologist, Dr Terry Brain, conducted an autopsy upon her. He observed that, as a result of the fall, she had suffered fatal injuries, being fractures to the base of the skull with bruising to the brain and subarachnoid haemorrhage. Dr Brain reported that subsequent interrogation of Mrs Greene’s pacemaker revealed a short eight second period of ventricular tachycardia (a very high heart rate) and a period immediately afterwards of asystole (no heart beat). The pacemaker subsequently showed no further heart activity. After significant analysis of the extracted pacemaker data and consultation with the pacemaker specialist, Dr Brain opined that the eight second period of cardiac arrhythmia occurred as a result of the fall rather than it being a natural heart episode causing a collapse and fall. I accept Dr Brain’s opinion and find that Mrs Greene tripped or lost her balance on the steps and suffered a fall causing fatal head injuries and, unfortunately, her death.

Comments and Recommendations Members of Mrs Greene’s family have raised the issue of whether the stairs upon which she fell were compliant with relevant building standards. They cited issues concerning narrow treads, lack of lighting and absence of a hand rail on the building side of the stairs.

I have received evidence from the Director of Medical Services Ambulance Tasmania to the effect that ambulance records from 2015 to the present time show no ambulance attendances by reason of falls on the same stairs. I have also received a report from the General Manager of the Circular Head Council stating that there has been no complaints raised with the Council regarding the stairs. The evidence of the hotel manager, Mr Julian Jacobs, is that in his 19 years of working at the hotel he has not known of any issues with the stairs, stating that numerous people use them on a daily basis. I further note that since Mrs Greene’s passing, the stairs have been cleaned, painted with white lines on each step and the lighting has been modified to provide extra illumination at night.

It may or may not be the case that the stairs in question do not strictly comply with relevant standards, given their construction many years ago. However, in absence of other incidents and in light of the safety features already in place, it is not appropriate to investigate this issue further in this finding.

I convey my condolences to Mrs Greene’s family and loved ones.

Dated 5 February 2021 at Hobart in the State of Tasmania.

Olivia McTaggart Coroner