Coroner's Finding: Cooper, Nelson Keith Cyril

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 Nelson Keith Cyril Cooper Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Nelson Keith Cyril Cooper (Mr Cooper); b) Mr Cooper died as a result of injuries sustained in a motor accident; c) Mr Cooper’s cause of death was multiple chest injuries; and d) Mr Cooper died on 7 May 2022 at Launceston, Tasmania.

In making the above findings I have had regard to the evidence gained in the investigation into Mr Cooper’s death. The evidence includes:  The Police Report of Death for the Coroner;  Tasmanian Health Service (THS) Death Report to Coroner;  Affidavits as to identity and life extinct;  Affidavit of the State forensic pathologist Dr Andrew Reid;  Affidavit of the forensic scientist Mr Neil McLachlan–Troup of Forensic Science Service Tasmania;  Medical records obtained from the THS;  Medical records obtained from Mr Cooper’s general practitioner;  Affidavit of Casey Perkins;  Affidavit of Miss Alex Ritchie;  Affidavit of Mrs Jacqueline Ritchie;  Affidavit of Peter Gibson;  Affidavit of Kieran Kroeze;  Affidavit of Sampath Thangalla;  Affidavit of Alexander Gibbons;  Affidavit of Merise Cooper;  Affidavit of Constable David Eaton;  Affidavit of Sergeant Scott McKinnell;

 Report of Constable Matthew O’Neil together with his scene diagram; and  Forensic and photographic evidence.

Introduction This investigation concerns a fatal two vehicle motor accident which occurred on the West Tamar Highway, Legana at its intersection with Bridgenorth Road on Thursday 5 May 2022 at approximately 7:15 pm. At that time Miss Ritchie was driving her mother’s 2007 Mazda 3 motor vehicle registered number J29NT (the Mazda) in a general northerly direction on West Tamar Highway. Mr Cooper was driving his daughter’s Holden Commodore sedan, registered number EF9893 (the Holden) in a general easterly direction on Bridgenorth Road towards its intersection with West Tamar Highway.

The road surface at the accident scene is constructed of a well-worn medium aggregate bitumen. There was nothing found to suggest that the roadway surface was in any way causative of this crash. At the time of the crash it had been raining on and off and the road surface was damp. Visibility was clear and there was no fog. The weather conditions did not contribute to the cause of this accident.

At the accident scene there is one lane on the West Tamar Highway for traffic travelling in a northerly direction and one for traffic travelling south. Bridgenorth Road also has one lane for traffic travelling east and one for traffic travelling west in the vicinity of the accident. At the intersection eastbound and westbound traffic on Bridgenorth Road are separated by a traffic island with another traffic island for vehicles entering Bridgenorth Road from the south or north. There is a painted give way line for vehicles turning right or left onto the West Tamar Highway and there is a clearly visible give way sign facing traffic wishing to perform either turn.

Background At the date of his death Mr Cooper was 80 years of age (date of birth 8 November 1941), he was divorced and he resided alone in Riverside. He was the holder of a current driver licence.

Mr Cooper was born in St Marys where he went to school and grew up. He was the second youngest of 12 children. Upon leaving school he worked in a number of jobs during his working life. This included working for the public works department as a sales representative.

Mr Cooper was married twice however he no longer had any contact with his first wife or his two children to his first wife. He met his second wife, Myrtle Street, and they moved to

Melbourne in 1963 but they returned to Launceston in about 1965. They were married in

1969. He and Myrtle had four children between 1965 and 1974. The third of those children died in 2004 and thereafter a rift formed between the two other children and both Mr Cooper and his oldest daughter Merise, as a result of which they no longer had any contact. Mr Cooper had separated from Mrs Cooper prior to the death of their daughter.

For the last 15 years of his life Mr Cooper had not been in a relationship. He had a number of close friends and enjoyed golf, tenpin bowling, cribbage, cards and square dancing. He was a smoker and a social drinker.

In so far as Mr Cooper’s health is concerned in 2021 and 2022 he suffered a pulmonary embolism and in 2022 he received treatment for a melanoma. As long ago as 2000 he was diagnosed with chronic obstructive pulmonary disease and in 2012 with gastro-oesophageal reflux. Two years later he was diagnosed with Barrett’s oesophagus and dysplasia and in 2015 he underwent an oesophageal endoscopic resection. He contracted pneumonia in 2021.

Hospital records disclose Mr Cooper was admitted for treatment in relation to a pulmonary embolism on 24 March 2022 and he was discharged on 28 March 2022. He had suffered severe calf pain after he had warmed up for his pennant bowls game. Those records also reveal Mr Cooper received treatment at the respiratory clinic of the Launceston General Hospital (LGH) in late 2021.

Circumstances Leading to Death Miss Ritchie and her mother, Jacqueline, were working at a chemist in Riverside up until 7 pm on 5 May 2022. Miss Ritchie was a novice L2 driver and was being instructed by her mother. She drove, with her headlights on, from the Riverside supermarket carpark left onto Cleghorn Avenue, left onto West Tamar Highway and south to the traffic lights at the intersection of Riverside Drive before making a right-hand turn and heading north on West Tamar Highway. Traffic was light and the road was damp.

At about 4 pm that day Mr Cooper had travelled to his daughter’s home at Bridgenorth Road which is something he did every Thursday. He was driving his daughter’s Holden, a vehicle he had been driving for three months as his had broken down. He had dinner with his daughter and her partner during which he consumed two Boags draught stubbies. He left at about 7 pm for the return journey home which is a distance of approximately 17 km.

As both vehicles entered the intersection Miss Ritchie had right of way however Mr Cooper did not stop and a collision occurred. Emergency services were contacted.

Investigation At approximately 7:15 pm Constable Eaton and Constable Rattray were tasked to attend this accident. They arrived five minutes later and the Mazda was observed to be situated across the southbound lane of West Tamar Highway with severe damage to the front and passenger side. The Holden was also positioned diagonally across the southbound lane and it was resting against the Armco railing on the eastern side of the highway. It had sustained damage to the driver side and front. Constable Eaton went to the assistance of the occupants of the Mazda whereas Constable Rattray went to the assistance of the occupant of the Holden. Constable Eaton radioed for assistance to help with traffic control and then removed several witches hats from the rear of the police vehicle and began diverting traffic up Bridgenorth Road. Further units attended and assisted with traffic control.

Ambulance Tasmania received the call to attend this accident at 7:19 pm and officers arrived at 7:31 pm. On the arrival of paramedics the occupants of the vehicles were assessed. They were all taken to the LGH for treatment. Due to the injuries sustained by Mr Cooper and Mrs Ritchie, Constable Eaton thought the crash may become more serious so as a precaution he marked the location of the vehicles with yellow paint and he took a number of photographs. He remained at the scene until the vehicles were removed and the road cleared.

On 7 May 2022 Constable Eaton was advised Mr Cooper had passed away from injuries he sustained in the accident. He was also informed Mrs Ritchie had been flown to the Royal Hobart Hospital due to the seriousness of her injuries. He therefore re-attended the accident scene in the company of Constable O’Neil from the Northern Crash Investigations Unit and briefed Constable O’Neil as to what he had done on the evening of the collision. In addition he obtained some CCTV footage from the nearby service station and a nearby residence. He also obtained a number of affidavits from witnesses.

Constable O’Neil inspected the scene and observed no skid marks, gouges or other scrapes attributable to the accident. Sergeant McKinnell attended at Constable O’Neil’s request and conducted a drone survey and Constable Williams also attended and took a series of photographs of the scene. Constable O’Neil took a number of measurements and then prepared a scene diagram.

Dr Reid performed a post-mortem examination on Mr Cooper on 10 May 2022. After conducting that examination and considering ante-mortem radiology and toxicology Dr Reid determined Mr Cooper’s cause of death was multiple chest injuries. This included a large right pneumothorax, small right haemothorax and partial collapse of the right lung together with multiple right-sided rib fractures and a minimally displaced right distal clavicle fracture.

In addition there was diffuse large volume soft tissue emphysema in the orbits, face, neck, chest, mediastinum and abdominal wall. There was no acute intracranial, cervical or intraabdominal injury. I accept Dr Reid’s opinion.

The testing performed by Mr McLachlan-Troup revealed Mr Cooper had a blood alcohol concentration of 0.081 g of alcohol in 100 mL of blood together with therapeutic levels of drugs which would have been administered during the medical treatment which Mr Cooper received after the accident. The effects of alcohol on the central nervous system (CNS) are well known. It is a depressant and alcohol’s effect on the CNS is proportional to its concentration in the blood and cognitive, sensory and motor disturbances increase at higher blood alcohol concentrations. The general effects include the loss of critical judgement, incoordination, reduced perception and awareness, impaired balance, sedation, nausea and vomiting, reduced responsiveness and decreased intellectual performance. Its consumption impairs critical functions required for driving including reaction time, coordination, information processing and reflexes. The reading returned in this case has, in the opinion of Mr McLachlan-Troup, “the potential to impair driving performance and increase relative crash risk.

It has been estimated that the relative risk of a driver with a blood alcohol concentration of between .075 g/100 mL and 0.120 g/100 mL being involved in a crash is approximately 5 to 12 times that of a driver with nil blood alcohol.” I accept the opinions of Mr McLachlan-Troup.

Mr Perkins is a qualified automotive technician with over 10 years’ experience in the automotive industry. He is employed as a transport safety and investigation officer with the Department of State Growth. On 12 and 18 May 2022 he inspected the Commodore and the Mazda at the Launceston Police compound. As a result of his inspection he determined there were two defects with the exhaust pipe on the Holden but other than that he says that vehicle was in a well-maintained condition. Those defects were not in any way causative of this accident. The Mazda was found to be in a well-maintained, roadworthy condition. It had no mechanical defects.

Miss Ritchie says she observed the Commodore coming along Bridgenorth Road but thought it was going to slow down. When it did not slow down she braked but was unable to avoid a collision. She says the Commodore came out in front of her.

Mrs Ritchie says she had been teaching her daughter to drive since September of the previous year and she was very familiar with the car she was driving. She was up to about 60 hours at the date of the accident. She says her daughter was still a tentative driver who needed a lot more hours. She was driving at about 65 km/h along the highway. She estimates the speed of the Commodore as she saw it travelling along Bridgenorth Road to be approximately 70 km/h.

Mr Gibson was driving directly behind Miss Ritchie. He says when he saw Mr Cooper’s vehicle he thought it was slowing down for the intersection but then it continued out onto the highway which left Miss Ritchie with “nowhere to go.” The CCTV footage shows Mr Cooper failed to stop at the intersection and he pulled out in front of Miss Ritchie who braked before impact.

Finally Ms Cooper says her father told her in the intensive care unit of the LGH he had not seen the other vehicle involved in the collision.

Comments and Recommendations Excessive speed, weather and road conditions and the road worthiness of the vehicles involved in this crash were not causative of it. I find from my investigation that this crash occurred when Mr Cooper failed to give way to Miss Ritchie when he pulled out onto the West Tamar Highway as Miss Ritchie was entering its intersection with Bridgenorth Road thereby giving her inadequate time and distance to avoid his vehicle. I accept what Mr Cooper told his daughter that he did not see the other vehicle involved because if he had observed the Mazda then I fully expect he would have slowed his vehicle to a stop and given way to that vehicle. The reasons why he did not see that vehicle include inattention and/or the consumption of alcohol.

I extend my appreciation to investigating officer Constable O’Neil for his investigation and report.

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

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

Dated: 14 August 2023 at Hobart, in the State of Tasmania.

Robert Webster Coroner