Coroner's Finding: Macpherson James Edward

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 James Edward MacPherson Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is James Edward MacPherson; b) Mr MacPherson died as a result of injuries sustained in a mountain bike crash in the circumstances set out in this finding; c) The cause of death was blunt trauma of the chest; and d) Mr MacPherson died on 11 March 2022 at Maydena, Tasmania.

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

• Police Report of Death for the Coroner;

• Affidavits verifying identification;

• Opinion of the forensic pathologist regarding cause of death;

• Toxicology report of Forensic Science Service Tasmania;

• Ambulance Tasmania Electronic Patient Care Record and Aeromedical and Retrieval Record;

• Medical Records from Richmond Medical Centre;

• Maydena Bike Park Patient Care Record and Incident Notification;

• Affidavit of Amberley Gittings, wife of Mr MacPherson;

• Statement of Adam Gregor, friend of Mr MacPherson;

• Affidavit of Rebecca Parrott-Foxen, Maydena Bike Park Safety Team Co-ordinator who provided first aid to Mr MacPherson;

• Affidavit of Kym Child, a nurse who provided first aid to Mr MacPherson;

• Affidavit of Simon French, owner of Maydena Bike Park;

• Affidavits of three attending and investigating police officers, including Forensic Services Officers and Crash Investigation Officers, together with photographs of the scene; and

• Affidavit of Transport Inspector regarding the condition of the mountain bike ridden by Mr MacPherson.

Background Mr MacPherson was born on 9 May 1992 at Derby in England and was 29 years of age at his death. He moved with his family to Australia in about 2001 and later moved to New Zealand. Mr MacPherson met his wife, Amberley Rose Gittings, in New Zealand in about 2008 and they married in 2018. In 2015 Mr MacPherson obtained employment at a speciality coffee company and the couple moved to Melbourne. At the time of his death, Mr MacPherson was in the late stages of opening his first café.

Mr MacPherson began road bike riding in around 2015 before commencing mountain bike riding about a year later. Mrs Gittings said in her affidavit that her husband was very passionate about riding, and conscious of choosing the right trail for his ability. He would often ride with a group of friends or on his own and was a competent, intermediate rider.

Circumstances of Death On 10 March 2022 Mr MacPherson travelled to Hobart with his friends Adam Gregor and Blair Gregor, who were brothers. Adam’s two sons, aged 10 years and 12 years respectively, were also in the group. They had planned a mountain biking holiday at the Maydena Bike Park (‘the bike park’). The group travelled directly from the Hobart airport to their accommodation in Maydena, stopping at New Norfolk for dinner.

At 8.30am the next morning, 11 March 2022, the group arrived at the bike park.

On arrival, they checked into the bike park, were given a colour coded wrist band which had the accident and emergency phone number printed on it and they signed the General Bike Park Waiver. Mr MacPherson had with him his own safety gear, including gloves, knee pads and goggles and the new helmet he had purchased for the trip. He had arranged to hire a Trek Slash 8 mountain bike (‘the bike’) from the bike park. The bike was last rented and serviced on 28 February 2022. Due to the bike being infrequently rented, the bike had not required any major servicing and was fit for purpose.

At approximately 12.00pm the group commenced riding on a track called “Dial It Down”.

The group had not previously ridden this track but had ridden other tracks at the park that

morning. This trail is classified as a blue trail which is denoted by a blue square1 and classed as intermediate/more difficult. The group were riding in the following order: Blair, Adam, Mr MacPherson and then Adam’s two sons. Adam considered the track to be easy and noted that it was a well-maintained machine-made track. Blair, being a cautious rider, set the pace at about 40km/h.

After riding approximately 200 metres, Adam travelled over a section of track with a straight descent before a tight left-hand bend. Just before the bend, the track had a fall of 9 degrees and, at the opening of the bend, the track was 2.4 metres wide. The track in this section is constructed with a berm, being a banked outside edge. Adam negotiated the bend without difficulty. However, after he had done so, he heard a bike rattle behind him followed by a loud thud. The sound was so unusual that it caused him to turn rapidly and fall off his own bike. When Adam was able to look behind him, he observed Mr MacPherson lying face down against the wall of the berm and the bike over an arm’s length away on the uphill side of the track.

Adam could see that Mr MacPherson was conscious but appeared winded and was having difficulty breathing. Adam assisted Mr MacPherson with removing his chin strap with which he was struggling. He could see that Mr MacPherson had injured his left wrist and right collarbone and was in obvious pain. His breathing improved but it remained laboured. It was at this time that Mr MacPherson, gaining awareness of his predicament, stated that he required a paramedic.

Blair had returned to the group after realising Adam and Mr MacPherson were no longer behind him. He assisted by identifying the track marker and calling the bike park emergency number. This call was taken by Jackie Poulson, a bike park employee who then relayed the information to Rebecca Parrott-Foxen. Ms Parrott-Foxen worked part-time as a Safety Team Co-ordinator for the bike park and, when she was not at the bike park, worked as a paramedic.

Ms Parrott-Foxen collected first aid materials and requested that Lucy Mackie2 (employee of the bike park) and Rhys Ellis (General Manager of the bike park) attend the scene with her.

Ms Mackie arrived at the scene first and made a call to Ms Parrott-Foxen at 12.05pm expressing concern regarding the severity of the injuries received by Mr MacPherson in the crash. Subsequently, Ms Parrott-Foxen made the decision to call Ambulance Tasmania State Operations Centre (SOC) to advise that a helicopter and other resources would likely be required prior to extricating him.

1 This signifies the difficulty level of the track and from the IMBA Trail Difficulty Rating System (TDRS).

2 This was Ms Mackie’s first shift and she had, at that time, recently qualified as a nurse.

At the time the weather was fine. There was no rain, but the ground was damp. The visibility was good with some fog present at the top of the mountain. This fog did not affect visibility.

First aid treatment provided to Mr MacPherson At 12.20pm Ms Parrott-Foxen arrived at the scene. She observed Mr MacPherson laying in the left hand berm. She observed him to be pale, clammy, with shallow breathing, but alert.

She requested that Ms Mackie obtain a full set of vital signs.

At 12.23pm she again contacted SOC to provide further details. She advised the operator she could see a pneumothorax (collapsed lung) to be developing. She auscultated3 Mr MacPherson, requested extrication equipment, conducted a full secondary survey and confirmed he did not have any head or spinal injuries.

At 12.30pm, Kym Child and her husband entered the vicinity of the incident as they were riding at the park for the day. Ms Child works casually as a registered nurse and enquired as to whether she could be of any assistance. Ms Parrott-Foxen accepted the offer of help.

Ms Child immediately assessed Mr MacPherson’s condition as serious. He was having difficulty breathing and began to spit up blood in increasing amounts. Ms Child splinted his injured left wrist and attempted to help him breathe.

At 12.50pm Mr MacPherson began to lose consciousness. Ms Parrott-Foxen attempted to insert an oropharyngeal airway but Mr MacPherson did not tolerate this so she instead commenced intermittent positive pressure ventilation via a bag valve mask. Ms Child took over, however Mr MacPherson completely stopped breathing within 30 seconds. CPR was commenced. Ms Parrott-Foxen again contacted SOC to advise of the cardiac arrest and discussed management with the retrieval consultant, Dr Konrad Blackman. After discussing numerous possibilities, Dr Blackman suggested an attempt at decompression of the tension pneumothorax with a bicycle spoke.

A spoke was removed from Ms Child’s bike. Ms Parrott-Foxen, with Dr Blackman providing advice, inserted the spoke into the correct area of MacPherson’s chest. She observed his chest begin to deflate.

At 1.22pm, a paramedic together with a volunteer of the Ouse Ambulance Station arrived at the scene. At this time, intravenous access was obtained, the bike spoke removed and defibrillator pads were placed on Mr MacPherson’s chest. The first rhythm check was conducted at which point Mr MacPherson was in Ventricular Fibrillation (VF), a shockable 3 Listened to his heart and lungs with a stethoscope.

heart rhythm. The first shock was then administered. Mr MacPherson remained in VF for the second rhythm check and a second shock was then administered. Mr MacPherson then went into asystole (a non-shockable rhythm) and remained this way for the next two rhythm checks. He then showed refractory VF and, whilst treatment took place, saline and adrenaline were administered to him.

At 2.15pm Dr Jo Kippax and Intensive Care Flight Paramedic Justin Blomeley arrived at the scene via helicopter. They undertook additional interventions upon Mr MacPherson, including bilateral finger thoracostomies, administration of additional blood, a cardiac ultrasound and creation of a surgical airway. Tragically, despite all attempts at resuscitation, Mr MacPherson passed away.

Tasmania Police was advised of the sudden death and specialist police officers attended the scene to retrieve Mr MacPherson and to commence examination of the scene and investigation of his death.

Investigation I am satisfied that a comprehensive investigation has been conducted into the death of Mr MacPherson.

The crash was unwitnessed and I am therefore unable to make positive findings about how the crash occurred. Tasmania Police crash investigators were unable to locate markings on the track which could have assisted with how it happened. Upon the evidence as a whole, the most likely cause is that Mr MacPherson attempted to negotiate the left hand bend to continue riding along the track and the front wheel of his bike turned 90 degrees to his direction of travel. This would likely cause the bike to stop moving and the rider to be thrown over the handlebars. The fact that Mr MacPherson was seen immediately following the crash lying face down and the bike some distance from him supports this being the most probable cause of the crash.

On 15 March 2022, an autopsy was conducted by experienced forensic pathologist Dr Donald Ritchey. In the opinion of Dr Ritchey, Mr MacPherson died as a result of severe blunt trauma, including bleeding, of the chest and lungs.

I further find that the first aid and treatment provided to Mr MacPherson by Ms Parrott-Foxen, Ms Lucy Mackie and Ms Kym Child was of a high standard despite the remoteness of the location, limited first aid resources and the severity of the situation. They could have done nothing more to assist Mr MacPherson.

As part of the investigation, an affidavit was provided by the bike park owner, Mr Simon French. I am satisfied that the bike park had appropriate policies and procedures relating to user safety in place at the time of Mr MacPherson’s death. I also note that Mr MacPherson signed the required waiver documentation before using the bike park.

Comments and Recommendations Mr MacPherson died, tragically, as a result of injuries sustained whilst accidentally crashing his mountain bike at the Maydena Bike Park. The investigation allows me to find that no other person was involved in the crash, that there were no defects or issues with the track or bike, and that Mr MacPherson was riding on a track suited to his ability wearing appropriate protective equipment.

The Maydena Bike Park opened in early 2018. Shortly after its opening, Colin Jamie Oliver, an experienced mountain bike rider, crashed his mountain bike on an easy “green circle” run and died as a result of his injuries.4 No deaths have occurred between that time and the death of Mr MacPherson.

I make no criticism of the Maydena Bike Park in respect of any issue connected with Mr MacPherson’s death.

Important safety precautions whilst mountain bike riding include using a properly maintained bike, appropriate protective equipment and riding on trails suited to the rider’s ability.

However, by the nature of the sport, the rider accepts that there is risk of injury and, occasionally, death.

I extend my appreciation to investigating officer, Constable Mandy Ladson, for her investigation and report.

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

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

Dated: 15 December 2023 at Hobart in the State of Tasmania.

Olivia McTaggart Coroner 4 Oliver, Colin Jamie [2020] TASCorC 78.