Coroner's Finding: Oates, Adam Grant

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 Adam Grant Oates Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Adam Grant Oates (Mr Oates); b) Mr Oates died as a result of injuries he sustained in a single vehicle crash; c) Mr Oates’s cause of death was extensive head injuries; and d) Mr Oates died on 31 July 2021 at Hobart, Tasmania.

Introduction This investigation concerns a fatal single vehicle crash that occurred on Middle Tea Tree Road, Richmond approximately 500 metres west of its intersection with Colebrook Road on 26 July 2021 at approximately 10.30pm. At that time Mr Oates was the driver and sole occupant of a Toyota Hilux utility registration number FC 5442 which was travelling east on Middle Tea Tree Road when he lost control and collided with a tree on the opposite side of the road. The weather at the time of the crash was fine and the road was dry.

In making the above findings I have had regard to the evidence gained in the comprehensive investigation into Mr Oates’ death. The evidence includes:  The Police Report of Death for the Coroner;  Affidavits establishing identity and life extinct;  Affidavit of Dr Christopher Lawrence Forensic Pathologist;  Forensic Science Service Tasmania – toxicological and analytical report;  Ambulance Tasmania electronic patient care record;  Affidavit of Mr Benjamin Hunt Transport, Safety and Investigation Officer, who inspected the vehicle involved in this crash;  Affidavit of Senior Constable Kelly Cordwell together with her Collision Analysis Report;

 Affidavit of Constable Debbie Morrisby;  Affidavit of Mr Grant Oates;  Affidavits of Mr Stephen Swan;  Affidavit of Mrs Joanne Swan;  Affidavit of Mr Jason Crusius;  Affidavit of Mr Bradley Oates;  Affidavit of Mr Thomas King;  Affidavit of Mr Jack Pyke;  Affidavit of Mr Sam Nichols;  Affidavit of Mr Jai Read;  Affidavit of Mr Jesse Round;  Affidavit of Ms Jasmine Smith;  Affidavit of Mr Zachary Browne;  Affidavit of senior Constable Rance Swinton together with photographs;  Tasmania police traffic crash report prepared by Constable Drew Redburn;  Mr Oates’ medical records obtained from Battery Point Medical and the Royal Hobart Hospital (RHH);  Driving licence history of Mr Oates and registration history of his motor vehicle; and  Body Worn Camera Footage and the results of a forensic examination of Mr Oates’ mobile telephone.

Background Mr Oates was born on 17 June 1999 in Perth, Western Australia and he was 22 years of age, single and he resided with a friend (Mr Zachary Browne) at the date of his death. He was the younger of two children to Grant and Alison Oates.

Mr Oates’s father, Grant, was a member of the Australian Army and as a result the family moved around in the early part of Mr Oates’ life. Initially the family resided in Perth Western Australia and after Mr Grant Oates completed his training in New South Wales the family moved to Victoria in 2001 and then to Townsville in Queensland in late 2003. At the end of 2004 the family moved to Tasmania.

As a youth Mr Oates competed in motocross racing and was a state champion downhill mountain bike rider. He had a settled upbringing and completed grade 10 at St Virgil’s College.

Mr Oates then gained an apprenticeship as an apprentice fitter and turner at the Cadbury factory in Hobart where he qualified after four years. He then obtained employment at a saw-mill in Bridgewater where he worked for about eight months before working with Precision Welding and Fabrication. At the beginning of 2021 Mr Oates was offered a position back at the Cadbury factory as an operator maintainer. He accepted that offer and remained in that employment up until the time of his death.

Mr Oates obtained his learner driver licence when he turned 16 years and then he obtained his provisional driver licence when he was 17. He purchased the vehicle involved in this crash at the beginning of 2021. He had been fined and he incurred 3 demerit points on 2 occasions in 2020 for failing to wear a seatbelt.

The Circumstances Leading to Mr Oates’ Death On 26 July 2021 Mr Oates was on a day off work and had arranged to help his brother, Bradley Oates, a builder by trade, who was building a house at Claremont. Mr Oates arrived at the property at 8.00am that morning and spent the day helping his brother before leaving at approximately 3.00pm.

Sometime between 3.00pm and 5.00pm Mr Oates visited a friend, Thomas King, with whom he spent up to an hour during which time he consumed 2 or 3 beers. He left Mr King’s address and said he was driving to The Crown Inn at Pontville. Instead he visited a friend at Pontville, Jack Pyke, and they consumed one beer each before Mr Oates left shortly before 6.00pm. Shortly thereafter Mr Oates met two friends, Mr Nichols and Mr Read, at The Crown Inn where Mr Oates consumed beer. At approximately 7.00pm he left The Crown Inn and drove to a friend’s home at Pontville. There he and Mr Round worked on a vehicle in a shed during which time Mr Oates consumed 2 to 3 cans of beer. Mr Round’s partner, Ms Smith, then drove Mr Round and Mr Oates to the Brighton Hotel where she played the pokies while Mr Round and Mr Oates remained outside smoking a cigarette. They only stayed a short time before Ms Smith drove them back to her home. Mr Round and Mr Oates returned to the shed for a short time before Mr Oates got into his vehicle at approximately 10.00pm to drive home.

The Circumstances of the Crash and its Aftermath At approximately 10.12pm Mr Oates called his friend Zachary Browne using his mobile phone while driving and informed Mr Browne he had just left Mr Round’s house and was on his way home. Mr Oates was driving on Ford Road, Pontville at the time of this call. At approximately 10.20pm Mr Oates sent a Snapchat video to a group of friends which included

Mr Brown, Mr King and Mr Read. The video was of Mr Oates driving his vehicle. Mr King believed Mr Oates was, at the time of the video, driving on Middle Tea Tree Road near the Coal Valley golf course. Mr Read believed Mr Oates was doing burnouts in his vehicle while recording himself on Snapchat but could not determine the location. Mr King responded to Mr Oates on Snapchat asking him if he had had a few drinks. At 10.22pm Mr King received a call from Mr Oates which lasted for about 2 minutes. According to Mr King Mr Oates sounded intoxicated, he was slurring his words and laughing. Mr Oates ended the call by telling Mr King he had to go and work on steering the vehicle home.

At 10.34pm police received a call to attend a serious motor accident on Middle Tea Tree Road. The first police officers on the scene were Senior Constable Redburn and First-Class Constable Morrisby from the Sorell police station who arrived at 10.47pm. The road was closed to traffic and crash investigation and forensic services were notified to attend.

Mr Swan was first on the scene. He observed Mr Oates in the driver’s seat of the vehicle.

He was unconscious. He noted Mr Oates was not wearing a seatbelt. He rendered assistance and called 000. His wife, Joanne Swan, was the second person on the scene. The third person on the scene was Mr Crusius who is a qualified first-aid responder and trainer.

He observed Mr Oates in the driver’s seat sitting upright being supported by Mr Swan. He observed Mr Oates had suffered a number of injuries. He obtained Mr Oates’ vital signs and observed Mr Oates was not wearing a seatbelt. He located a mobile phone in the foot-well near Mr Oates’ left foot.

Senior Constable Swinton arrived at the scene at 11.25pm and after being briefed by Senior Constable Redburn and First-Class Constable Morrisby he photographed the scene. Senior Constable Cordwell from crash investigation services arrived at the scene at 12.08am on 27 July 2021. The scene was marked and measurements of relevant incident marks were recorded.

Post-Mortem Examination A post-mortem examination was conducted by Dr Christopher Lawrence on 2 August 2021.

As a result of that examination and after considering the RHH records, which included a CT scan and MRI scans of the brain and cervical spine, Dr Lawrence determined Mr Oates had suffered extensive head injuries which included a left extradural haemorrhage and a large right subdural haemorrhage of the brain, facial base of skull fractures, right frontal contusions, a probable diffuse vascular injury involving the corpus callosum, thalamus and brain stem and soft tissue injuries to the cervical spine at C3 to C7. Attempts at the RHH to decompress the head injuries were not successful. Dr Lawrence concluded Mr Oates died as result of head injuries sustained in this motor accident. I accept Dr Lawrence’s opinion.

Dr Lawrence notes the findings of Mr McLachlan-Troup set out in his report from Forensic Science Service Tasmania. Testing of ante-mortem blood returned a blood alcohol reading of 0.214 g of alcohol in 100 mL of blood. This reading is in excess of 4 times the legal limit prescribed under the Road Safety (Alcohol and Drugs) Act 1970. In his report Mr McLachlanTroup says alcohol is a central nervous system (CNS) depressant. Generally speaking the effects of alcohol on the CNS are proportional to its concentration in the blood and cognitive, sensory and motor disturbances increase at higher blood alcohol concentrations.

General effects of alcohol include loss of critical judgement, incoordination, reduced perception and awareness, impaired balance, sedation, nausea and vomiting, reduced responsiveness and decreased intellectual performance. The depression of psycho motor and cognitive functions due to alcohol causes impairment of critical functions required for driving including reaction time, coordination, information processing and reflexes. There is also an associated increase in risk-taking and speed variation. Mr McLachlan-Troup says it has been estimated the relative risk of a driver with a blood alcohol concentration of 0.180 g of alcohol in 100 mL of blood being involved in a crash is approximately 50 times that of a driver with a nil blood alcohol reading. Given the reading in this case was higher then he says Mr Oates was at an even greater risk of being involved in a crash. I accept the opinions of Mr McLachlan-Troup.

Crash Investigation The crash investigation in this matter is contained in the affidavit and report of Senior Constable Cordwell. Having considered her qualifications I am satisfied Senior Constable Cordwell is qualified to express the opinions contained in those documents.

At the time of her arrival Senior Constable Cordwell says it was dark, the weather was fine and the recorded temperature was 12°C. The roadway was dry and in reasonable repair.

Middle Tea Tree Road has a single lane for vehicles travelling east and a single lane for vehicles to travel west. The east and westbound lanes are divided by a single continuous white line. Both lanes measured 2.7 m wide. The northern side of the road was bordered by gravel and a deep culvert. On the southern side of the road was a line of trees running parallel to a timber fence surrounding the property known as Prospect House. The area of impact was a tree at the rear entrance to this property.

The first incident mark was identified as a tyre mark in the gravel verge on the northern side of the eastbound lane. This mark commenced approximately 51 m west of the impact. The initial tyre mark commenced on the western side of a laneway on the exit to a right-hand curve. From examination of the road Senior Constable Cordwell noted a heavy indentation (rut) in the gravel road edge on the northern side of the eastbound lane. She says it is

evident that it is common practice for vehicles travelling east to take the corner wide and drop the left wheels over the bitumen road edge into the gravel. When conducting a survey later that day she observed a number of eastbound vehicles entering the rut. From the tyre marks Constable Cordwell says Mr Oates has exited the rut in the gravel prior to the laneway on the northern side of the road. He has continued to travel in the gravel over the laneway before running the left wheels of his vehicle very close to the culvert. He has then applied harsh right-hand steering input which has caused the vehicle to rotate in a clockwise direction rendering it uncontrollable.

An analysis conducted from the rear left tyre marks indicate the vehicle was travelling at 75 km/h on exiting the gravel verge at the eastern end of the scene. This part of the tyre mark showed obvious striations on the bitumen and across the white centreline indicating the rear tyre was side slipping, rotating and was not under maximum braking. The tyre mark from commencement to conclusion measured 51 m in length. The final 14.7 m of the mark were on the bitumen where the mark continued in a general south-easterly direction toward impact with a tree. At the conclusion of the tyre marks on the southern side of the westbound lane was a grass verge bordered by a timber fence. On the eastern end of the fence was a driveway to enter the property known as Prospect House. On the western side of the driveway is a tree. It measured approximately 1 m in diameter at its thickest point below the branches. Damage on the tree extended from a point approximately 80 cm from the base up to a height of approximately 1.5 m to damage on a limb. From examination of the damage to the tree and vehicle Senior Constable Cordwell was satisfied that the front of the vehicle has collided heavily with this section of the tree. After contact with the tree the vehicle has rotated in a clockwise direction colliding with the timber fence before coming to rest on the bitumen roadway approximately 1.4 m north east of the tree. The vehicle was on the eastern side of the tree facing in a general southerly direction. The front wheels were resting on the grass verge of the westbound lane and the rear of the vehicle had come to rest in the westbound lane. The vehicle had sustained direct impact damage to the front right side. Inside the vehicle there was damage to the steering wheel and dashboard with the steering wheel being forced upward which is consistent with driver impact. Indentations in the dashboard in line with the driver’s knees are consistent with impact by an unrestrained driver. The seatbelt had been wound around the seat adjustment leaver. No signs of trauma were identified on the driver’s seat belt. It had been rendered inoperable because it was wrapped around the seat adjustment lever. Senior Constable Cordwell is satisfied the seatbelt was not worn at the time of the crash. I accept her opinions as expressed above.

Inspection of the Vehicle Benjamin Hunt is a qualified automotive mechanic with in excess of 15 years’ experience in the automotive industry. He has inspected a number of vehicles involved in serious or fatal crashes. On 2 August 2021 he inspected the vehicle involved in this crash. His inspection revealed the vehicle to have a number of unapproved modifications with numerous defective issues identified. He determined the vehicle was un-roadworthy and not compliant. I accept Mr Hunt’s opinion.

Senior Constable Cordwell says none of these defects appear to have contributed to the crash. I accept her opinion on that issue.

Accident Cause Senior Constable Cordwell has expressed the opinion that, as a result of her inspection of the scene, the vehicle and after analysing all the evidence available, excessive speed was not a factor in this crash. The speed calculated at the commencement of the yaw mark was 75 km/h. The vehicle would have slowed over the duration of the yaw mark, however, the remaining marks were insufficient to establish a speed at impact. Harsh right-hand steering input from the driver has contributed to the loss of control. In addition she says he was not wearing a seatbelt and the injuries he sustained are consistent with an unrestrained driver being propelled forward due to rapid deceleration on impact with the tree. Although wearing a seatbelt under these circumstances would have prevented Mr Oates from striking the steering wheel she cannot categorically state that a restrained driver would not have suffered fatal internal or neck injuries due to sudden deceleration on impact. I accept the opinions of Senior Constable Cordwell.

Comments and Recommendations Given the evidence in this case I find if Mr Oates had not consumed alcohol to excess and had not used his phone while he was driving along Middle Tea Tree Road then he would not have lost control of his vehicle and crashed into a tree. Had he been wearing his seat belt when he crashed into the tree then the risk of him sustaining fatal head injuries would have been significantly reduced.

I extend my appreciation to investigating officer Senior Constable Kelly Cordwell for her investigation and to First-Class Constable Morrisby for her report.

The circumstances of Mr Oates’ death are not such as to require me to make any comments or recommendations pursuant to Section 28 of the Coroners Act 1995 other than what follows. Although Senior Constable Cordwell did not identify the rut on the northern side of

the east bound lane as a contributing factor to the crash she recommended the local council assess the rut and potentially repair it. I agree. I therefore recommend the Clarence City Council assess this rut and repair it if the assessment deems it necessary.

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

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

Robert Webster Coroner