Coroner's Finding: Baker, Christopher John

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 Christopher John Brian Baker Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Christopher John Brian Baker; b) Mr Baker died in the circumstances set out in this finding; c) Mr Baker’s cause of death was drowning; and d) Mr Baker died on 9 June 2021 at Deviot, Tasmania.

In making the above findings, I have had regard to the evidence gained in the comprehensive investigation into Mr Baker’s death. The evidence includes:  The Tasmania Police Report of Death;  Affidavits establishing life extinct and identification;  Opinion of the forensic pathologist regarding cause of death;  Toxicology report of Forensic Science Service Tasmania;  Affidavit of Robyn Elizabeth Baker, wife of Mr Baker;  Affidavits of witnesses to the circumstances surrounding death;  Affidavits of attending and investigating police officers;  Marine and Safety Tasmania (MAST) life jacket inspection report;  Bureau of Meteorology, Central North District Forecast Report 8-9 June 2021;  Documentation evidencing motorboat licence renewal, certificate of boat registration, and permit for registration of mooring;  Information from MAST regarding construction and maintenance of moorings;  Medical records and reports pertaining to Mr Baker’s health; and  Forensic and photographic evidence.

Christopher John Brian Baker was born on 23 March 1954 and was 66 years of age at the time of his death. He is survived by his wife, Mrs Robyn Baker, and his two adult children.

During his working life, Mr Baker’s primary occupation was that of an electrician working in domestic, commercial, and mining areas, but he also spent time working as a dredge operator, dredging the Tamar River. He had been healthy during his working life but retired in 2014 due to health issues. Although he continued to suffer some health issues after that time, these were unrelated to the circumstances of his death.

Mr Baker was a very experienced sailor. He and Mrs Baker had an extensive history of sailing together over many years. In 2019 they purchased a new vessel, Yarindi III, a Mottle 33 ft monohull yacht. They sailed the boat back from Kettering to their home at Deviot on the West Tamar. Mr Baker had Gravelly Beach Marine build and install the mooring specifically for the yacht. The mooring was situated in the Tamar River in front of their house.

Circumstances of Death On Wednesday 9 June 2021, the weather in the Deviot area was windy, with south-easterly winds blowing at approximately 40-50 km/h. White caps could be seen forming on the river.

At about 2.00pm, Mrs Baker was in the kitchen overlooking the river and noticed that the yacht was drifting north pulling its mooring. Mrs Baker told Mr Baker and they decided to go out and retrieve the yacht.

Mr Baker took with him two Burke yoke-style life jackets and the outboard motor from the garage. The dinghy used to access the yacht was kept on the beach in front of the house. Both Mr and Mrs Baker fitted their life jacket before leaving the shore in the dinghy. Mrs Baker sat at the front of the dinghy whilst Mr Baker sat at the back and operated the outboard motor.

When Mr and Mrs Baker reached the yacht, it was bucking heavily in the waves. Mr Baker steered the dinghy to its stern, where Mrs Baker was able to put the rope from the dinghy around the bottom step on the fixed yacht ladder. Mrs Baker then handed the rope to Mr Baker and told him to hold on whilst she climbed aboard. Mrs Baker was able to climb aboard but when she went to grab the rope from Mr Baker, she could not reach it. Mr Baker reached out and grabbed the ladder with his left hand and tried to pass Mrs Baker the rope with his right hand. As he did so a large wave came and he lost grip on both the ladder and rope and began to drift away in the dinghy.

As Mr Baker attempted to re-start the dinghy, another big wave came and overturned the dinghy with Mr Baker in it. Mrs Baker witnessed this event and called 000, requesting police

and ambulance assistance. Mrs Baker could see Mr Baker and the dinghy drifting away from her in a northerly direction moving closer to shore.

Witness Robin Sim, who provided an affidavit for the investigation, stated that whilst sitting at her dining room table overlooking the river she could see a dinghy floating down the river.

Upon taking a closer look through her binoculars she realised that a person wearing a yellow life jacket was holding onto the dinghy. Ms Sim moved down to the shoreline. There, she could see that the male person (later identified as Mr Baker) had inflated his life jacket and was holding onto the upturned dinghy. As Ms Sim called out to Mr Baker, he appeared to turn his head and raise his arm at her.

At 2.49pm Tasmania Police Radio Room received the first call regarding the incident. Senior Constable Jarrod Burleigh and Constable Karen Griffith of Exeter Police Station were tasked to attend the scene. Senior Constable Burleigh arrived first at around 3.19pm as he was already in the area. Senior Constable Burleigh ran down to the shoreline where he was met by Ms Sim who had followed Mr Baker along the river. Senior Constable Burleigh could see that Mr Baker was holding onto the dinghy with his left hand whilst he continued to drift closer to shore and that Mr Baker’s inflated life jacket was positioned high up around his head.

At 3.21pm Senior Constable Burleigh estimated that the dinghy was about 10 metres from shore and had drifted close enough that Mr Baker attempted to stand. This was observed by Ms Sim and another witness, Mr Peter O’Keefe. Senior Constable Burleigh and Ms Sim looked away briefly whilst in discussion about what had occurred and when they turned back to Mr Baker, they observed that he was now face down in the water.

At this point, Senior Constable Burleigh entered the water and dragged Mr Baker to shore. He noted that Mr Baker was unconscious and not breathing. He commenced CPR immediately with the assistance of witness Ms Sim. Whilst continuing CPR Senior Constable Burleigh radioed for assistance from police and ambulance and asked Constable Griffiths to locate a defibrillator and bring it to the scene.

At 3.35pm Constable Griffiths arrived with the defibrillator and the device ran through three cycles before Ambulance Tasmania officers arrived. They determined that Mr Baker was deceased. Mr Baker was conveyed by mortuary ambulance to the mortuary at the Launceston General Hospital before being taken to Hobart for post-mortem examination.

An autopsy was performed by experienced forensic pathologist, Dr Christopher Lawrence. Dr Lawrence noted that Mr Baker’s lungs appeared overexpanded and he identified significant narrowing of two coronary arteries in Mr Baker’s heart and also that his heart was enlarged,

indicative of heart disease. In Dr Lawrence’s opinion, Mr Baker died as a result of drowning. He was of the opinion that Mr Baker’s heart disease likely hastened his death but was not the major cause of death. I accept the opinion of Dr Lawrence. I note also that Mr Baker did not have any alcohol or illicit substances in his system at the time of his death.

Comments and Recommendations Most unfortunately, Mr Baker drowned following an attempt to secure his yacht which had begun to drag its mooring during unusually severe weather conditions. Whilst it was understandable that Mr and Mrs Baker made the decision to protect their yacht, it was an unwise decision in the circumstances.

Whilst Mr Baker was in the water, a duration of approximately 30 minutes, he was wearing an inflated life jacket. It was a 150 Burke manually inflatable yoke jacket, which was found to be in good working order. However, the inflated life jacket had risen to a position above Mr Baker’s head, increasing his risk of drowning over the extended period in which he was in the water.

The life jacket worn by Mr Baker was not fitted with a crotch strap and was not required by regulation to have a crotch strap. The report received from Marine and Safety Tasmania (MAST) emphasised that lifejackets fitted with crotch straps prevent the life jacket from riding high on the wearer and, as such, increases the protection from drowning.

In this investigation, the investigating officer raised the issue of the need for increased regulation of moorings as being a potential matter for comment. I have received in response a helpful reply from MAST concerning this issue. It is clear that the regulatory scheme currently places significant onus upon permit holders to ensure that their mooring is suitable for its intended use. However, MAST conducts audits of moorings to ensure compliance of particular mooring requirements in accordance with the Marine and Safety (Mooring) By-laws 2020.

In this case, I do not consider that there is sufficient causative connection to Mr Baker’s death to make further comment on the issue. Moorings may still move in severe weather events, despite appropriate design and construction. Mr Baker’s mooring had not previously shown any indication that it was not fit for its purpose and may well have been in good condition. Ultimately, Mr Baker made the unfortunate decision to take the dinghy to his yacht, which led to the events causing his death.

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

I extend my appreciation to the investigating officer Senior Constable Jarrod Burleigh for his investigation. I acknowledge his efforts in recovery of Mr Baker from the water and prolonged attempts at resuscitating him.

I convey my sincere condolences to the family and loved ones of Christopher John Brian Baker.

Dated: 13 June 2022 at Hobart Coroners Court in the State of Tasmania.

Olivia McTaggart Coroner