Coroner's Finding: Creely, Colin Wayne

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Robert Webster, Coroner, having investigated the death of Collin Wayne Creely Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Collin Wayne Creely (Mr Creely); b) Mr Creely died from injuries sustained in a fall from a mountain bike at St Helens, Tasmania; c) Mr Creely’s cause of death was a cervical and thoracic spine injury; and d) Mr Creely died on 29 October 2021 at St Helens, Tasmania.

Introduction In making the above findings, I have had regard to the evidence gained in the investigation into Mr Creely’s death which included the following:  Tasmania Police Report of Death for the Coroner;  Affidavits as to identity and life extinct;  Affidavit of the forensic pathologist Dr Andrew Reid;  Affidavit of the forensic scientist from Forensic Science Service Tasmania Mr Neil McLachlan-Troup;  Affidavit of Mrs Carol Creely;  Affidavit of Mr Andrew Kurtukoff;  Affidavit of Mr Stefan Michajlow;  Affidavit of Mr Michael Heaton;  Affidavit of Mr Marcus Brown;  Affidavit of Mr Anthony Perkins;  Affidavit of Mr Isaac Perkins;  Affidavit of Mr Lester Jeffrey  Affidavit of Constable Christopher Minehan;

 Affidavit of First-Class Constable Giuliano Ercole;  Affidavit of Senior Constable Tracy Lincoln;  Ambulance Tasmania (AT) electronic patient care record;  Mr Creely’s medical records obtained from his general practitioner; and  Forensic and photographic evidence together with body worn camera footage.

Background Mr Creely was 67 years of age, married to his wife Carol and retired at the date of his death.

He had known Mrs Creely for about 50 years and they married on 9 October 1976. They have 2 children, a daughter Angela, and a son Matthew.

Mr Creely was born on the 25 September 1954 in Deloraine. His parents are Leon and Lorna Creely. Mr Creely was the oldest of 6 siblings. He spent his first 10 years growing up in Brontë Park from where his family moved to Golden Valley near Deloraine. He attended Deloraine High School in years 7 and 8 after which he completed his schooling and assisted his family on their farm for a number of years. He then worked at a sawmill after which, at the age of 19, he applied for a job at Savage River where he worked for the next 5 years and qualified as a painter. Mr Creely then worked for Tascott Carpet Factory in East Devonport for a year before he commenced working at the Wesley Vale paper mill. He remained in that employment for the next 31 years until that business closed down in about 2010. Thereafter Mr Creely worked as a builder’s labourer and then as a groundsman for the Education Department. He retired at the age of 65.

Mrs Creely says her husband had no major health concerns during his lifetime. He always enjoyed playing sport which included football, squash, racquetball bushwalking and mountain and road biking. He tried to ride about 3 to 4 times per week and as he became fitter the rides became longer. He started mountain biking about 5 years ago and really enjoyed it.

Mrs Creely says her husband knew his limits on the bike and would always know when to stop.

He never tried to do any jumps or manoeuvres he did not think he could manage. His love of riding encouraged him to give up smoking in his early 30s.

Health The general practitioner’s records commence on 12 June 2001. They reveal Mr Creely suffered from back pain, sciatica and neck, hip and shoulder pain for many years. He smoked cigarettes and drank alcohol. From time to time he suffered from abdominal pain and chest pain. He was diagnosed with osteoarthritis of both hips. A national bowel screening test conducted in 2020

was positive and he was referred for a colonoscopy which took place on 18 February 2021.

That procedure revealed no invasive malignancy but it did detect polyps with tubular adenoma1 with high-grade dysplasia2.

Mr Creely’s most significant condition was hypercholesterolemia3 which is first mentioned in the records on 29 September 2003. It is last mentioned in the third last entry. Blood tests were regularly arranged in order to manage this condition. In addition Mr Creely underwent a number of electrocardiograms4 (ECG) and an exercise ECG which is conducted to assess the heart’s response to stress or exercise. It seems on a number of occasions, including on the third last visit, Mr Creely declined prescription medication and instead chose to manage this condition by modifying his diet. There is a note that at one stage this had resulted in the loss of 18 kg. It is also clear from the records Mr Creely exercised regularly which included playing racquet sports and mountain bike riding.

Circumstances Leading to Mr Creely’s Death On 29 October 2021 Mr Creely travelled from Latrobe with Michael Heaton, Stefan Michajlow and Marcus Brown to the east coast of Tasmania where they intended to stay in St Helens and ride the mountain bike trails at St Helens, Derby and Blue Tier. They had planned to ride at Derby on 29 October 2021 but because of the weather they continued their journey to St Helens. They stopped at the Pub in the Paddock for lunch. Mr Creely was driving and they were all travelling in his vehicle. They travelled on to St Helens and unloaded the car on arrival.

As the weather had cleared they decided to ride the trails at St Helens. They were all riding E bikes.

Mr Heaton says they had been riding for about an hour and reached a section of a trail where they all stopped at the top and chatted. Mr Heaton left first, followed by Mr Brown, Mr Michajlow and then Mr Creely. Mr Brown says “[a]s a group we pretty much just rolled down the track.” Mr Heaton believes he would have finished riding before Mr Creely commenced his descent. Mr Heaton says he stopped and watched the others come down. He says he did not 1 Pre-cancerous polyps.

2 Pre-cancerous changes in the cells of the oesophagus.

3 This is a very high level of low density lipoprotein (LDL) cholesterol in the blood. LDL cholesterol is known as "bad" cholesterol because it can build up in the walls of the arteries thereby making them hard and narrow.

4 An electrocardiogram is a medical test that detects heart problems by measuring the electrical activity generated by the heart as it contracts.

see Mr Creely fall but he saw both him and his bike sliding on the trail. Neither Mr Brown or Mr Michajlow saw what occurred.

Mr Anthony Perkins was present at the end of the trail on which Mr Creely was riding and he was talking to a friend; Mr Briant. He was there with his son Isaac. At about 16:10 hours he looked up and saw Mr Creely fall sideways off his bike and land on his side. He says he only saw Mr Creely about 2 seconds before he hit the ground. Mr Isaac Perkins says he was with his father when he watched Mr Creely come down the hill over the “whoops”5 when he went over the handlebars. Mr Perkins says he was about 300 m away at this time.

Mr Heaton immediately went back up the trail to the crash point to assist Mr Creely. He was followed by Mr Brown, Mr Michajlow, Mr Briant and both Anthony and Isaac Perkins. When Mr Heaton reached Mr Creely Mr Heaton says Mr Creely was conscious and lying on the track. He did not try to sit or stand. He recognised Mr Heaton and said something like “I can’t breathe”.

Mr Heaton says Mr Creely was only moving his lips; that is he was mouthing the words not saying them. Mr Heaton repeated the phrase to Mr Creely to confirm it and he acknowledged this by moving his lips again. He then passed out. They commenced CPR and contacted emergency services. There was also a discussion as to whether there was a defibrillator in the vicinity. As a result Mr Jordan Murray went to the cafe connected to the mountain bike park and obtained a defibrillator. He returned and those assisting Mr Creely followed the instructions on the machine on 3 to 4 occasions before officers from AT arrived. Mr Anthony Perkins says on each occasion the machine advised no shock was administered. Ambulance officers and police arrived. Treatment continued however Mr Creely could not be revived.

Investigation The records of AT indicate the call for assistance was received at 16:03 hours and a unit was dispatched at 16:05 hours. Officers were at the scene at 16:17 hours and commenced treatment at 16:20 hours. Treatment continued until it was ceased at 16:55 hours.

The forensic pathologist Dr Andrew Reid carried out a post-mortem examination on 2 November 2021. That examination revealed a dislocation fracture of the upper cervical spine (C1/C2) and a mid thoracic (T4) spinal fracture. He also found significant coronary 5 This is a series of undulations like speed humps on the mountain bike trail. They are designed to make the ride more difficult and to slow riders down.

atherosclerosis6, myocardial fibrosis7 and left ventricular hypertrophy8. He notes on toxicology salicylic acid was found at a concentration in the sub therapeutic range. That acid is a principal ingredient of aspirin which is a non-steroidal anti-inflammatory drug widely available without prescription. Dr Reid therefore concluded the results of toxicology did not contribute to either the cause of death or the circumstances in which it arose.

Dr Reid says the nature and degree of the coronary atherosclerosis and the ischaemic myocardial fibrosis would have been sufficient to cause sudden death as would the nature and degree of the cervical and thoracic spinal injuries. Dr Reid goes on to say there is no evidence to suggest Mr Creely was travelling at speed and he lost control of the bike. The possibility of a myocardial event proceeding fatal trauma cannot be excluded however the evidence Mr Creely was able to communicate to indicate breathing difficulties before he lost consciousness suggests that any preceding cardiac event had not been immediately fatal. Dr Reid says “[i]t is not possible to determine whether any preceding cardiac event would have been subsequently fatal without subsequent trauma. However if any preceding cardiac event would have been non-fatal then, inevitably, the traumatic injuries would have been the primary cause of death”. Dr Reid therefore concludes by saying the cause of death was the cervical and thoracic spinal injuries and he notes coronary atherosclerosis, myocardial fibrosis and left ventricular hypertrophy were other significant contributory conditions. I accept Dr Reid’s opinion.

Police arrived at approximately 16:20 hours. The investigating officer, Constable Minehan is an experienced mountain bike rider who knows the particular trails at this mountain bike park well. Witnesses were spoken to and statements were taken. Mr Creely’s phone, Apple smartwatch and bike were seized. A forensics officer, Constable Ercole arrived at 19:30 hours and took photographs. Senior Constable Lincoln received the smartwatch and mobile phone belonging to Mr Creely. She attempted to charge the watch but it would not charge or turn on.

She downloaded and analysed the data from the phone. She determined a health app on the phone had not been set up, the free Strava9 app on the phone had not been used since 31 May 2021 and another app called Ride with GPS was on the phone but not logged on. Accordingly nothing forensically useful was obtained from the watch or the phone.

6 Atherosclerosis is thickening or hardening of the arteries caused by a build-up of plaque in the inner lining of an artery. Risk factors may include high cholesterol and triglyceride levels, high blood pressure, smoking, diabetes, and obesity.

7 Myocardial fibrosis is defined as an increased quantity of collagenous scar tissue in the heart. Myocardial fibrosis may arise as a result of cardiac disease and it is associated with an unfavorable prognosis.

8 Left ventricular hypertrophy is a thickening of the wall of the heart's main pumping chamber. This thickening may result in an elevation of pressure within the heart and sometimes a poor pumping action.

The most common cause of this condition is high blood pressure.

9 Strava GPS Cycling and Running App is an app that permits tracking of running and riding with GPS.

This accident occurred at St Helens Mountain Bike Trails which is situated on Flagstaff Road approximately 6 km south of St Helens. There are 18 different trails. Trails in Australia are designated as green for beginners or inexperienced riders, blue for intermediate riders, black or black diamond for expert riders and there are also orange or ‘pro – lines’. There are none above black at this facility. The trail on which Mr Creely was riding was called Icarus which is rated as a black trail. This trail starts on Scamander Tier and runs down the hill towards Flagstaff Road. The last few hundred metres of this trail, where this accident occurred, runs parallel to Flagstaff Road. Mr Kurtukoff is an experienced rider. He was present on the day of this accident. He says, in his view, the black trails at St Helens are really only difficult blue trails.

Constable Minehan agrees with Mr Kurtukoff and says in his view the Icarus trail is not a black trail but just a difficult blue trail.

Mr Creely’s friends say he was a conservative rider who would never push himself, who rode within his capabilities and always rolled down hills. Mr Isaac Perkins says the section of track where Mr Creely fell can be described as containing mellow small rises that can be rolled through easily. He says it is not a section of track that involves jumping or skilled riding and he thinks “anyone could roll down through there.” Having considered some footage of this section of the track I agree with him. He had also seen Mr Creely riding earlier in the day and he describes him as “very cautious and he was not going fast at this stage, I believed he was playing safe.” Mr Creely was observed by police to be lying substantially parallel to the track with his feet downhill between the third and fourth whoops on the downhill run. He was wearing a helmet and kneepads. Constable Minehan activated his body worn camera and began questioning witnesses to determine what occurred. He knew some of the people present as riders he had seen on trails around Devonport and Latrobe and he realised subsequently he had met Mr Creely at a friend’s shack at St Helens before he was transferred there. He determined Mr Micahajlow had recorded the day’s events on his GoPro camera which was later obtained.

Constable Minehan says this footage shows a large amount of the riding of Mr Creely from behind, most of it being on a trail called Send Helens. The footage does not show Mr Creely crashing but shows him seconds before and seconds after the crash. Having watched the footage on several occasions Constable Minehan says Mr Creeley and his friends were all riding very carefully, within their skill set and they appear to be looking after one another. He determined from the witnesses that nobody could say what the cause of the crash was. He determined all said Mr Creely was riding carefully and within his skill set which is consistent with what Constable Minehan says the footage shows. Constable Minehan says from viewing

the damage to Mr Creely’s helmet and the marks on the ground in the footage10 he believes Mr Creely has come forward over the bike with force but he does not know what caused this.

This is consistent with what Mr Isaac Perkins says occurred.

On 1 November 2021 Constable Minehan inspected Mr Creely’s bike. Apart from a slight gear misalignment all mechanisms appeared to him to be in proper working order. On 26 December 2021 Constable Minehan inspected the bike more thoroughly and checked the motor/battery including for the speed at which the motor cut out. He says it is supposed to cease assistance at 25 km/h but using his GPS watch, which he uses to track all his physical exercise and which also shows the assistance on his private E bike ceases at exactly 25 km/h, he obtained an assisted speed of over 35 km/h. The speedo on Mr Creeley’s bike showed a speed of only about 20 km/h when he was travelling at 35 km/h. Constable Minehan says this indicates the motor had been de-restricted by manipulating the speed sensor which is a common modification. This he says means the pushbike is actually a motorcycle under the relevant legislation11. Constable Minehan is however of the view this modification did not contribute to the accident because the distance from where Mr Creely commenced riding to where he crashed is so short that he would not have reached a speed of 25 km/h. In addition the modification only allows a greater speed, it does not permit the motor to accelerate any harder. From where he commenced his descent there would have been no need for Mr Creely to peddle at all. I accept the opinions of Constable Minehan.

Comments and Recommendations The state of the evidence is such that I cannot determine what caused Mr Creely to crash. He could have had a medical episode and/or he could have lost concentration. Because of the manner of his riding on this day I am satisfied excessive speed played no part in the cause of the crash. He died as a result of the injuries sustained in the crash. His bike was in proper working order and there was nothing about the track itself which caused or contributed to the crash.

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

10 These were disturbed by those who went to Mr Creely's aid and so this is why the marks observed at the scene were not used by Constable Minehan in his assessment.

11 Vehicle and Traffic Act 1999 and the definition of motor bike and motor cycle in s3 and the Vehicle Standard (Australian Design Rule – Definitions and Vehicle Categories) 2005.

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

Dated: 21 December 2022 at Hobart in the State of Tasmania.

Robert Webster Coroner