Coroner's Finding: Bell Mary and David

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 Mary Amelia Bell and David Lewis Bell Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Mary Amelia Bell (Mrs Bell); b) Mrs Bell died as a result of injuries sustained as a front seat passenger of a vehicle which was involved in a two vehicle crash; c) Mrs Bell’s cause of death was a head injury; and d) Mrs Bell died on 29 August 2020 at Bridgenorth, Tasmania.

Find, pursuant to Section 28(1) of the Coroners Act 1995, that e) The identity of the deceased is David Lewis Bell (Mr Bell); f) Mr Bell died as a result of injuries sustained as the driver of a vehicle which was involved in a two vehicle crash; g) Mr Bell’s cause of death was a head injury; and h) Mr Bell died on 29 August 2020 at Bridgenorth, Tasmania.

Introduction This investigation concerns a fatal two vehicle crash which occurred at approximately 2:30pm on 29 August 2020 at the intersection of Bridgenorth Road and Long Plains Road at Bridgenorth in Tasmania. At about that time Mr Bell was driving a blue Toyota Corolla sedan registration number EN 4665 south along Long Plains Road towards its intersection with Bridgenorth Road. Mrs Bell was a front seat passenger in that vehicle. At the same time Joe Barker (Mr Barker) was driving a Toyota Hilux utility registered number C 79 VL west along

Bridgenorth Road towards its intersection with Long Plains Road when the crash occurred.

At the time of the crash the weather was fine and dry and there was good visibility.

In making the above findings I have had regard to the evidence gained in the comprehensive investigation into Mr and Mrs Bell’s deaths. The evidence includes:  The Police Report of Death for the Coroner;  Affidavits as to identity and life extinct;  Affidavits of the pathologist Dr Ruchira Fernando;  Report of Mr Craig Gardner, approved analyst under the Road Safety (Alcohol and Drugs) Act 1970 of Forensic Science Service Tasmania and affidavits of Mr Neil McLachlan-Troup, forensic scientist of Forensic Science Service Tasmania;  Records obtained from Ambulance Tasmania (AT)  Affidavit of First-Class Constable Nigel Housego, Crash Investigator  Affidavit of Mr Barry Spencer, Transport Safety and Investigation Officer;  Affidavit of Mr Barker;  Affidavit of Mr Brock Dillon, the passenger in the vehicle driven by Mr Barker;  Affidavit of Mr Danny Williams;  Affidavit of Mr John Bell, son of Mr and Mrs Bell;  Affidavit of Constable Matthew O’Neill;  Affidavit of First-Class Constable Brett Tyson together with photographs;  Affidavit of Senior Constable Peter McCarron together with photographs;  Medical records from Kings Meadows Family Practice and the Northern Suburbs Medical Centre; and  Forensic evidence.

Background – Mary Bell Mary Amelia Bell was born Mary Amelia Harris on 25 July 1939 at Deloraine, Tasmania. At the time of her death she was aged 81 years. Mrs Bell worked as a bookkeeper at McKinlay’s in Launceston before working full-time at home.

Background – David Bell David Lewis Bell was born on 24 May 1938 at Burnie, Tasmania. At the time of his death he was aged 82 years. After leaving school Mr Bell worked as a bus driver for what is now known as Metro Tasmania Pty Ltd for most of his working life. He retired at the age of 65 years.

Further Background Mary Harris and David Bell met at a dance at St Albies Hall, in Margaret Street Launceston.

They married in their early twenties and built a house in Newnham where they resided until the crash. Mr and Mrs Bell had three children; Michelle, John and Stephen. After Mr Bell’s retirement, Mr and Mrs Bell regularly visited their children at various locations in Australia and they were both active members of the Ravenswood Bowls Club, with Mrs Bell being the Secretary and later the Treasurer. They were approaching their 60th wedding anniversary at the time of their deaths.

Mrs Bell was being treated for a number of conditions by her general practitioner which included asthma, gastro-oesophageal reflux disease and hypertension and she is described by her son, John, as healthier than his father. Mr Bell had a number of health issues, having recently been treated for bowel and prostate cancer. John Bell says his father had lost a lot weight. He also used a walking stick and he suffered from severe arthritis in both knees.

The Circumstances Leading to Mr and Mrs Bell’s Death Mr Barker had spent most of the morning on 29 August 2020 with his friend Mr Dillon. He picked Mr Dillon up from his home in Riverside at approximately 9:30am after dropping his girlfriend, Sophie Lewis, off at work in Launceston. Mr Barker then drove to his home at Rosevale1 where they fitted a bash plate to the underside of Mr Barker’s vehicle. At approximately 12:30pm Mr Barker and Mr Dillon then travelled to Legana along Bridgenorth Road to get some lunch. After consuming their lunch and visiting some shops at Legana Mr Barker then drove his vehicle, with Mr Dillon as a front seat passenger, from Legana along Bridgenorth Road. Their intention was to return to Mr Barker’s home at Rosevale. As they approached the intersection with Long Plains Road Mr Barker estimates his speed was about 80 km per hour.

On the day of the crash, Mr and Mrs Bell have most likely been out on what their son, Mr John Bell, describes as “a drive down the West Tamar area. I can’t think of anyone that they would have visited down the West Tamar. This is not unusual, given they quite often went for a drive.” CCTV footage obtained from Shakers Takeaway on the West Tamar Highway at Exeter, depicts Mrs Bell walking into the store, making a purchase and then leaving at around 2:20pm on the day of the crash. The vehicle is not sighted travelling past the store prior to her trip to the shop. First-Class Constable Housego says this suggests Mr and Mrs Bell have 1 Which is approximately 10 km from the accident scene west along Bridgenorth Road.

travelled from their home in Newnham, north along the East Tamar Highway, then west on the Batman Highway crossing the Tamar River via the Batman Bridge. From there it is most likely they turned left off the Batman Highway onto the West Tamar Highway and south to Exeter stopping north of Shakers Takeaway which is on the western side of the highway, just south of Frankford Highway.

To travel to the crash scene, after leaving the takeaway store, Mr and Mrs Bell have travelled west on the Frankford Highway from Exeter, and then left onto Long Plains Road. They have then travelled south towards Bridgenorth Road. On approach to the intersection they had travelled close to the speed limit2, passed a give way sign which is erected 150 m before the intersection with Bridgenorth Road and then passed a give way sign which is erected at the intersection of Long Plains Road and Bridgenorth Road.

The Circumstances of the Crash and its Aftermath At approximately 2:30pm Mr Bell was driving the blue Toyota Corolla sedan south on Long Plains Road towards its intersection with Bridgenorth Road. At the same time Mr Barker was driving his white Toyota Hilux utility west on Bridgenorth Road towards its intersection with Long Plains Road. Mr Williams says he noticed the Corolla was not slowing down for the intersection so he started to slow his vehicle. He believed the Corolla was going to just keep going through the intersection without stopping. He lost sight of the Corolla because of a house on his left hand side and then after he drove past the house he noticed the Corolla was much closer to the intersection and travelling at the same speed. He then saw a white Toyota Hilux come around the bend, travelling towards him at a speed of approximately 70 km/h. He anticipated a crash would occur so he stopped his vehicle and it occurred in front of him. He said the Corolla appeared to be continuing up Stokes Lane3 without slowing or giving way. It was about three quarters of the way across the intersection when the Hilux drove into the passenger side door area of the Corolla. He says the Corolla was spun around and ended up facing west against the fence up on the verge on the south western side of the intersection. The Hilux spun in the opposite direction to the Corolla, its wheel dug in and it flipped ending up on its roof near the back of the Corolla and facing north. Prior to the crash he says he could see the driver of the Corolla was an elderly man who was looking straight ahead up the road. He called 000.

2 This is the evidence of Mr Williams who was driving east along Bridgenorth Road towards Legana and who looked to his left and saw Mr Bell's vehicle travelling south on Long Plains Road. At the time he first saw Mr Bell's vehicle it was approximately 300 m from the intersection.

3 Long Plains Road crosses Bridgenorth Road and continues in a general southerly direction at which point it becomes Stokes Lane.

Mr Barker says he recalls approaching the intersection of Bridgenorth Road and Long Plains Road. He had just come around a slight left-hand corner and was driving slightly uphill on Bridgenorth Road. He was on his side of the road. He knows there are give way signs at the intersection because he travels the road often. He knew the traffic approaching Bridgenorth Road from Long Plains Road and from Stokes Lane had to give way to his vehicle. He did not see any cars on the road at the time he approached the intersection and believed it was clear to proceed through the intersection. He says it was not until he entered the intersection he saw the Corolla on his right hand side. A collision then occurred. He said he did not have time to brake or react in any way.

Constable Matthew O’Neill was tasked to attend this crash at approximately 2:35pm. He arrived, in the company of Constable Bridget Tyson, at 2:40pm. He spoke to Mr Barker and Mr Dillon and determined the occupants of the Corolla were deceased. He also spoke to Mr Williams.

First-Class Constable Housego from northern crash investigation services was tasked to attend this crash and he arrived at 2:59pm. On arrival he was briefed by Constable O’Neill.

Arrangements were made for a blood sample to be obtained from Mr Barker at the Launceston General Hospital. First Class Constable Housego then conducted an inspection of the crash scene and surrounding area. He noted the Corolla displayed extensive impact damage to the passenger side and secondary damage to the rear driver side guard area. Both Mr and Mrs Bell were wearing their seatbelts. The Hilux had visible impact damage to the front bull bar area. With the assistance of First-Class Constable Chynoweth and Senior Constable Mathieson, First-Class Constable Housego marked the location of the vehicles, tyre scuffs, scrapes and gouges with yellow road marking paint and wooden stakes. He then completed a scene sketch which included relevant measurements. First-Class Constable Brett Tyson and Senior Constable McCarron of Northern forensic services attended the scene and took photographs and drone footage at his direction. The mortuary ambulance attended and with the assistance of Tasmania Fire Service officers, Mr and Mrs Bell were removed from the Corolla and transported to the mortuary. Both vehicles were then seized and conveyed to the police compound in Launceston for mechanical inspection.

On Monday, 31 August 2020 First-Class Constable Housego attended the police compound and completed sketch drawings of the damage to both vehicles. He found the centre front of the Hilux had impacted with the passenger side of the Corolla, 660 mm from the front of the vehicle. He had the airbag modules removed from the vehicles for later download and he also removed tail and brake light globes from each vehicle for analysis.

Post-Mortem and Toxicological Examination A post-mortem examination was conducted by Dr Fernando with respect to Mrs Bell on 31 August 2020. She found Mrs Bell had sustained a number of musculoskeletal fractures including a fracture of the left middle fossa, jaw and fracture dislocation of the atlanto-axial junction. In addition, Mrs Bell sustained a fractured pelvis and a complete transection of the vertebral column at T8/T9 together with multiple rib fractures. She sustained a sub arachnoid haemorrhage to the brain. These injuries were fatal.

Dr Fernando conducted a post-mortem examination with respect to Mr Bell on 31 August

2020. She determined he sustained multiple rib fractures bilaterally, a left shoulder dislocation and a left clavicular fracture. In addition he sustained a small sub arachnoid haemorrhage over the right parietal lobe of the brain as well as an associated intraventricular haemorrhage on the right side. There was a base of skull fracture involving the sphenoid bone and the middle cranial fossa. This head injury caused Mr Bell’s death.

I accept the opinions of Dr Fernando.

An analysis of samples taken at autopsy confirmed Mr Bell had no alcohol or illicit drugs in his blood. The only results of note were therapeutic and sub therapeutic concentrations of prescribed medication. None of these drugs had any effect on Mr Bell’s ability to drive a motor vehicle. I accept the opinions of Mr McLachlan-Troup with respect to these matters which are set out in his affidavit.

Mr Gardner says in his report testing of the blood sample taken from Mr Barker after the accident revealed alcohol and drugs were not present in his blood.

Crash Investigation First-Class Constable Housego sets out in his affidavit the various measurements he took on both Bridgenorth Road and Long Plains Road. His affidavit also details the location of various scuff and gouges in the surface of the roads and verges. He also conducted a speed analysis on this crash and he determined that neither vehicle would have been exceeding the 100 km/h speed limit. His results had the Hilux travelling at about 82 km/h and the Corolla at around 95 km/h. He also noted the estimated speeds provided by Mr Williams, Mr Barker and Mr Dillon. Given those estimates and his speed analysis he is satisfied neither vehicle involved in this crash had been exceeding the speed limit.

First-Class Constable Housego also conducted site line testing at the intersection. He says there are large trees on the property on the north-eastern corner of the intersection which limits the view of motorists at the intersection. He measured the approximate location the

drivers of each vehicle would be positioned at the first time they could see the other vehicle approaching the intersection. He marked these locations with paint and then measured the distance each mark was from the area of impact. The distance from the impact for the Corolla on Long Plains Road was 27.1 m and it was 26.8 m for the Hilux to the impact area on Bridgenorth Road. He used the approximate speeds for each vehicle and an average perception response time of 1.3 seconds but noted Mr Bell has driven straight through the intersection with no evidence of braking. This suggests Mr Bell may not even have identified the intersection for what it was, as a result of which First-Class Constable Housego suggests Mr Bell’s perception response time should be adjusted to that of a driver on a straight section of road where the average response time is said to be 1.8 seconds. In addition he notes there was no deceleration by either vehicle prior to the collision and therefore it was possible to calculate the distance required for each driver to perceive the other driver and commence some form of action to prevent a collision. This he says is done by multiplying the velocity of the vehicle with the perception response time of the driver of that vehicle.

On the assumption Mr Barker was travelling at around 70 km/h (19.444 m/s) with a response time of 1.3 seconds then he has travelled 25.278 m. In Mr Bell’s case he was travelling at approximately 95 km/h or 26.389 m/s which when multiplied by 1.8 seconds is 47.5 m. Given one of those distances was well in excess of the distance from the vehicle to the point of impact and the other distance was very close to the distance between the vehicle and the point of impact First Class Constable Housego says that evidence alone establishes that neither driver could have taken action to avoid a collision. They simply did not have enough time. With this evidence First-Class Constable Housego calculated the time it would take Mr Barker to travel the 26.8 m which was his line of sight. He determined from his calculations that when Mr Barker was 26.8 m from the point of impact Mr Bell was approximately 36.364 m from the point of impact. The earliest possible location Mr Barker would have seen the approaching Corolla was at 27.1 m, so this crash could not have been avoided by Mr Barker.

Inspection of the Vehicles Barry Spencer is a qualified automotive mechanic with in excess of 30 years’ experience in the automotive industry. He is employed as a transport, safety and investigation officer with the Department of State Growth. On 31 August 2020 he inspected the blue Corolla and on 2 September 2020 he inspected the white Hilux involved in this crash. After conducting his inspection of the Corolla he determined this vehicle would have been in a roadworthy condition prior to the crash. He was unable to locate any vehicle defects or faults which may have caused or contributed to the crash. In particular he found no fault with the brakes of

the vehicle. After conducting his inspection of the Hilux he found 3 vehicle defects4 but he says none of them would have caused or contributed to the crash. I accept Mr Spencer’s opinions.

First-Class Constable Housego was able to download data recorded on the SRS airbag module in the Hilux utility. However due to the age of the vehicle the information obtained was limited to the longitudinal change in velocity of the vehicle during the collision. That data indicated in the first 200 milliseconds during the collision the velocity of the vehicle decreased by 35.6 km per hour. First-Class Constable Housego says collisions are generally completed during this time and therefore this was the likely maximum velocity change of that vehicle during this collision. I accept his opinion.

Inspection of the tail light bulbs taken from both vehicles found no distortion to the brake light filaments. First-Class Constable Housego says this is evidence supporting the road surface evidence that neither vehicle was braking prior to impact. I accept his opinion.

Accident Cause First-Class Constable Housego says inspection of the vehicles found no faults in either of them that may have contributed to the collision. There is no suggestion in the lay evidence or from the post-mortem examination of Mr Bell that suggests a medical event was the cause of this collision. I note Mr Williams says Mr Bell was looking straight ahead up the roadway and looked to have tunnel vision of the roadway ahead. First-Class Constable Housego says in his opinion both vehicles were travelling within the speed limit, weather conditions did not contribute to the crash and neither did the condition of the roadway. In addition the consumption of alcohol and drugs was not a contributing factor. First-Class Constable Housego’s time/distance analysis also found Mr Barker did not have sufficient time to take any action to avoid a collision. In addition First-Class Constable Housego says the following: “Mr Bell has driven the Corolla south on Long Plains Road, passing a give way ahead sign, then a give way sign and then crossed a painted line on the roadway to cross the intersection with Bridgenorth Road. He has failed to observe these warning signs that he was approaching the intersection. It is my opinion that he has believed that Stokes Lane, (on the other side of Bridgenorth Road), was a continuation of Long Plains Road and did not identify the need to slow or stop for Bridgenorth Road.

4The first one was an LED light bar was attached to the roof rack and located across the front roof area of the vehicle. The second was after market wheels 70 mm over the maximum allowable wheel track which causes the tyres to slightly protrude outside the body line of the vehicle. The third defect was the vehicle was not fitted with mudflaps to its rear wheels.

This suggests there has been a level of inattention associated with Mr Bell’s driving. The intersection is clearly marked, and an attentive driver should be aware that they are approaching this intersection and take action to avoid a collision with any vehicles travelling on Bridgenorth Road.

Witness Danny Williams stated that he saw Mr Bell looking straight ahead as he was travelling up to and into the intersection. He appears to have been watching where he was going but has not perceived the warnings prior to the intersection.” Accordingly First-Class Constable Housego concludes the crash occurred due to Mr Bell’s inattention. I agree.

Recommendations Made by First Class Constable Housego and Response from the West Tamar Council Traffic crash data obtained from the Department of State Growth reveals that prior to this fatal crash there had been four previous accidents at this intersection which occurred in 2010, 2013, 2016 and 2017.

First-Class Constable Housego noted that since this crash road markings and signage have been upgraded at the intersection, with ripple strips placed across the southbound lane of Long Plains Road. He noted with time these measures will fade and wear down and he recommended to me that a more permanent solution is warranted. He noted the lack of deviation travel pathways when travelling south on Long Plains Road and onto Stokes Lane.

He indicated drivers may not identify that Stokes Lane is a separate roadway, requiring driver input, despite the presence of signs and road markings. He recommended a forced deviation travel pathway through roadway realignment would assist in reducing crashes and he noted a similar realignment at the intersection of Roseburn and Bridgenorth Roads. The manager for infrastructure, Mr Harper, at West Tamar Council was advised of those recommendations and he responded by advising the remedial works, undertaken as interim measures between 29 August 2020 and 18 February 2021 included the following:  “A review of the existing traffic signage arrangements and geometry of the intersection;  Traffic signage has been increased to the largest available size in accordance with Australian Standard AS1742.2 part 2 Manual of uniform traffic control;  GIVE WAY pavement painting on the Long Plains Road;  Traverse rumble strips on the southbound lane of Long Plains Road to warn drivers regarding the presence of intersection ahead;  Vegetation clearing and trimming to improve sight distance;  A grant application has been submitted for FY 2021/22 Black Spot Funding Program;

 Continuous liaison with the Department of State Growth as to road geometry improvements and safety enhancements.” Mr Harper goes on to say the council, with advice and support from the Department of State Growth, intends to realign intersection geometry through a staggered T-junction. He says that will improve the safety of the intersection. An external engineering consultancy firm was engaged to investigate and design the junction realignment, a capital budget allocation has been proposed and if approved by Council a tender process would be initiated and a civil contractor would be engaged to perform the works.

I agree with Mr Harper that these works will improve the safety of the intersection.

Since Mr Harper’s email the West Tamar Council has reported the required investigation and design process, land acquisition and formal tendering of the works has taken place.

Invitations to tender opened on 9 November 2022 and the tender was awarded to a civil construction company on 21 December 2022. It is envisaged the realignment of the intersection will take approximately 11 weeks to complete and that work will be completed between mid-February and the end of April 2023.

Comments and Recommendations I extend my appreciation to investigating officer First-Class Constable Nigel Housego for his investigation and report.

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

This case serves as a timely reminder that momentary lapses in concentration or inattentiveness by drivers of motor vehicles can have tragic consequences.

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

Dated: 6 March 2023 at Hobart in the State of Tasmania.

Robert Webster Coroner