Coroner's Finding: Gudge, Gian George

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 Gian George Gudge.

Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Gian George Gudge; b) Mr Gudge died as a result of injuries sustained in a single motorcycle crash; c) Mr Gudge’s cause of death was neck and chest injuries sustained in that single motorcyle crash; and d) Mr Gudge died on 20 May 2022 at Launceston in Tasmania.

In making the above findings I have had regard to the evidence gained in the comprehensive investigation into Mr Gudge’s death. The evidence includes:

• The Police Report of Death for the Coroner;

• Affidavits as to identity and life extinct;

• Affidavit of the forensic pathologist Dr Christopher Lawrence;

• Affidavit of the forensic scientist Mr Neil McLachlan–Troup of Forensic Science Service Tasmania;

• Affidavit of Mr Barry Spencer;

• Affidavit of Ms Kaysha Blundstone;

• Affidavit of Ms Rebecca Lee;

• Affidavit of Sergeant David Gammon;

• Affidavit of First-Class Constable Darren Chynoweth;

• Affidavit of First-Class Constable Nigel Housego;

• affidavit of First-Class Constable Brett Tyson;

• Medical records obtained from Mr Gudge’s general practitioner;

• Records obtained from ambulance Tasmania (AT); and

• Sketch plan, forensic evidence and photographs.

Introduction This investigation involves a single motorcycle collision that occurred at approximately 7:10 pm on Friday 20 May 2022 outside 69 Wentworth Street in Newstead. At that time Mr Gudge was riding a blue 2000 Suzuki GSXR 1000 motorcycle, Tasmania registration number RY419 (the motorcycle) west along Wentworth Street.

This crash occurred just after a slight right-hand bend outside number 69 Wentworth Street which has a prescribed speed limit of 50 km per hour. Wentworth Street travels east – west, from Penquite road at the eastern end to High Street at the western end. Wentworth Street itself is approximately 935 m in length with several streets which intersect it, including a roundabout. It is in an urban area of Launceston with houses with driveways and footpaths on both sides of the street for most of its length. In addition to houses there is a church, a PCYC and a small business on the northern side of the street.

The road surface in Wentworth Street, at the scene of this crash, is constructed of an aggregate bitumen mix which was in good condition with no visible surface defects. An inspection of the scene after the crash located nothing on the roadway’s surface that would have caused the crash. The roadway in the vicinity of the crash is approximately 9.8 m wide with an uphill gradient, travelling west, of 10.8%. The street has formed concrete kerbing but no road markings. There is a 3.5 m wide grass verge between the kerbing and a 1.5 m wide concrete path on the southern edge of the street. Front fences of houses are adjacent to the footpath.

At the time of this crash the weather was fine and the road surface was dry. No rain had been recorded during the day.

Background Mr Gudge was 35 years of age (date of birth 14 March 1987), he was employed as a concreter, and he had been in a de facto relationship for almost 4 years with Ms Lee at the date of his death.

Mr Gudge was born in Queensland to Matthew Gudge and Lorraine Tuffin. He had a difficult relationship with his mother and little to do with his father. He had 4 brothers one of whom is deceased. Ms Lee says Mr Gudge attended school until year 8 and that he and his family moved around quite a lot.

On leaving school Mr Gudge was employed in a number of manually based occupations. He subsequently had 2 daughters in Victoria to 2 different women. He did not have very much contact with his daughters.

Mr Gudge moved to Tasmania in 2016 and lived in Hobart for approximately 3 months before he moved to Launceston. After a period of time, he obtained his own rental property in Mayfield and was there for about 12 months before he met Ms Lee. While in Tasmania Mr Gudge was again employed in a number of manually based occupations. Ms Lee says he loved riding motorcycles and BMX push bikes.

Mr Gudge had the motorcycle for about 2 years. He used to race the motorcycle at Tasmanian Motorcycle Association events, and he would attend Symmons Plains Raceway on a semiregular basis. Ms Lee says Mr Gudge was not a cautious rider and often took risks. This was a source of tension between them. Ms Lee says she did not want him to have the motorcycle.

Circumstances Leading to Death On Friday, 20 May 2022 Ms Lee was staying with her brother in Newstead. She had been separated from Mr Gudge for about 4 months. At 6 pm that evening Mr Gudge visited Ms Lee at which time he had dinner with Ms Lee and her brother, and he consumed 2 small glasses of whiskey. After dinner his intention was to return home to feed his birds, have a shower and return for the night. They had booked their motor vehicle in to have its tyres checked at 10:30 am the next morning and Mr Gudge was going to take the vehicle in.

After dinner Mr Gudge rode away on the motorcycle. Subsequently Ms Lee became aware of the crash and that Mr Gudge had passed away.

Investigation Sergeant Gammon was advised of the crash at about 7:11 pm and that officers from AT were already at the scene. He drove to the scene and determined the crash had occurred outside 69 Wentworth Street which is between the intersections of that street with Strahan Road and Junction Street. He parked his vehicle near the intersection with Strahan Road thereby closing Wentworth Street to other traffic. He was the first police unit to arrive. He provided instructions to other police units to establish road closure points. Sergeant Gammon observed the position of Mr Gudge, that he was being treated by paramedics, and the position of the motorcycle on the roadway. He spoke to a number of people who were present. He requested

the attendance of officers from Northern Crash Investigation Services and Northern Forensic Services and he remained in control of the scene until First Class Constables Chynoweth and Tyson attended.

First-Class Constable Chynoweth was tasked to attend the crash scene at 7:45 pm. On arrival he was briefed, and he inspected the scene and the surrounding area. He saw some evidence of scraping on the gutter, gouges in the grass embankment, tyre scuffs on the road surface and vehicle debris and damage to the steel handrail of the staircase which was situated between the road and footpath. He noted the motorcycle had sustained relatively minor damage. From his observations he prepared a sketch plan that included relevant measurements. First-Class Constable Tyson took photographs at his direction.

On 1 June 2022 First Class Constable Housego attended the crash scene with Senior Constable Rybka who had requested his assistance to determine if a speed analysis could be conducted from the available evidence. First-Class Constable Housego inspected the scene and the sketch plan. He says the sketch was an accurate representation of what he observed. He determined he was unable to conduct an accurate speed analysis from the evidence available however that evidence and damage to the motorcycle suggested the motorcycle was not travelling at excessive speed. He determined Mr Gudge failed to make a very slight right turn by riding straight on or through the corner thereby clipping the kerbing. He continued along the kerbing until he has impacted with the steel handrail. First-Class Constable Housego says once the motorcycle hit the kerbing Mr Gudge was not able to recover from that position and this occurred due to inattentiveness. He said there was no evidence of another vehicle being involved because Mr Gudge has continued in a straight line which is not consistent with him veering to avoid an approaching vehicle. I accept his opinion.

Mr Spencer is a transport safety and investigation officer employed by the Department of State Growth. He is a qualified automotive mechanic within excess of 30 years’ experience in the automotive industry. During this time, he has undertaken numerous roadworthiness examinations of vehicles involved in serious and fatal crashes. He inspected the motorcycle on 1 June 2022. He determined as a result of his inspection the motorcycle was unroadworthy as it had a sticky and binding throttle. The throttle would not allow the engine to run to idle when released. He was unable to locate any other faults or defects which may have caused or contributed to the crash. He also advised this defect was not caused by any impact during the crash but by an incorrect cable adjustment. He says it may have had a negative effect on the safe operation and control of the motorcycle in certain circumstances. I accept Mr Spencer’s opinion.

Dr Lawrence carried out his post-mortem examination on 24 May 2022. As a result of that examination and after considering CT findings and other medical records he determined Mr Gudge sustained a fracture dislocation of the cervical spine at C6 – 7 with likely transection of the cord, upper rib fractures, a left pneumothorax and an epidural haemorrhage in the head.

Accordingly, he determined Mr Gudge died as a consequence of neck and chest injuries following this crash. He says the cervical dislocation alone would be sufficient to account for his death. I accept his opinion.

AT received the call to attend this crash at 7:12 pm. Officers were at the scene 5 minutes later.

On their arrival bystanders were providing CPR. Resuscitation efforts were continued by ambulance personnel and throughout Mr Gudge’s transport to the Department of Emergency Medicine of the Launceston General Hospital. On arrival the trauma team were ready and made further attempts to resuscitate Mr Gudge which were unsuccessful.

Mr McLachlan–Troup says testing of Mr Gudge’s blood returned a blood alcohol reading of 0.121 g of alcohol in 100 mL of blood. He says alcohol at that level had the potential to significantly 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 0.120 g/100 mL and 0.180 g/100mL of blood being involved in a crash is approximately 12 to 50 times that of a driver with no alcohol in his or her blood. Given the reading in this case there was a significant risk that the consumption of alcohol would have affected Mr Gudge’s critical judgement, coordination, perception and awareness, and balance. I am satisfied this was the major factor which led to his inattentiveness which in turn led to the crash.

Finally, I note Mr Gudge did not hold a driver licence in Tasmania let alone a licence to operate a motorcycle. He did have a Victorian driver licence. He had been disqualified from driving until 10 May 2022 as a result of being convicted and suspended due to driving a motor vehicle while a prescribed drug was present in his oral fluid. He had one prior matter for driving with alcohol in his body in excess of the prescribed concentration which led to a conviction and disqualification from driving for a period of 3 months up until 10 February 2022. Clearly, he should not have been riding the motorcycle on this evening.

Comments and Recommendations Having investigated this matter, I am satisfied the crash was not contributed to by any other vehicle or driver. In addition weather conditions and the condition of the road surface did not in any way cause or contribute to the crash. Neither was excessive speed a factor. The crash

occurred because of inattention which resulted in Mr Gudge failing to navigate the slight righthand bend on Wentworth Street just prior to the accident scene. I am satisfied this inattention was due to the consumption of alcohol.

The circumstances of Mr Gudge’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 Gudge.

Dated: 25 August 2023 at Hobart in the State of Tasmania.

Robert Webster Coroner