Coroner's Finding: Ridgway, Gavin

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Leigh Mackey, Coroner, have investigated the death of Gavin Ridgway.

Mr Ridgway was born in Melbourne on 26 September 1970. He was 52 years old when he died. In 2013, he moved to Tasmania initially living and working on King Island before moving to Burnie in 2018. He worked primarily as a self-employed handyman and possessed skills as a tiler and roofer. Mr Ridgway was in a de-facto relationship with Joanne Haddow at the time of his death.

Mr Ridgway owned and enjoyed riding motorcycles. In 2019 he bought a one-off custom-built black 2016 Harley Davison replica, in Deloraine. During the summer months he rode the motorcycle almost daily and in the weeks prior to his death entered it in the Ulverstone Motorcycle Show where it won the “Top Chopper” category. The motorcycle was Mr Ridgway’s “pride and joy”.1 Mr Ridgway was in good physical health prior to his death. He did not smoke and only drank alcohol infrequently and socially. Mr Ridgway died after being involved in a single vehicle motorcycle accident.

The motorcycle The motorcycle was a 2016 Harley Davidson replica individually constructed vehicle (ICV), commonly referred to as a “chopper”. The style of motorcycle is characterised by long raked out front forks, a narrow front tyre and a very wide rear tyre.2 Choppers are primarily designed for their look rather than their function. They have less clearance for cornering than conventional road motorcycles and unless being driven in a straight line can be difficult to manoeuvre.3 1 Affidavit of Joanne Haddow sworn 28 April 2023 p2.

2 Tasmania Police subject report 21 May 2023 p6.

3 Tasmania Police subject report 21 May 2023 p6.

Mr Ridgway’s replica chopper was fitted with unusually large tyres at the front and the rear.4 This would have negatively impacted the handling of the front tyre as its 21-inch front rim likely created a greater “gyroscopic effect” causing the bike to be more resistant to turning.5 The width of the rear tyre also would have caused a greater resistance to turning as the flatter profile of the tyre prevents the motorcycle from leaning. The style of front forks gives rise to a slower reaction to rider inputs and causes a heavier feel to the steering. Considering these matters, the width of the tyres and the raking front forks, the motorcycle was not suited to riding on winding roads.6 Mr Ridgway’s friend, Mr Kurtus Williams had previously ridden the motorbike and found that it was not easy to ride, particularly around corners.7 After Mr Ridgway’s accident the motorcycle was inspected by Transport Safety and Investigation Officer Philip Evans. Whilst that inspection revealed non compliances including worn rear brake pads to the degree of metal-on-metal contact when braking, a loud exhaust system, absence of red reflectors on the rear of the motorcycle, and inadequate coverage and guarding of the drive belt and pulleys, it is unlikely that any of these defects contributed to the accident. I note in this regard the absence of any braking effort by Mr Ridgway prior to the accident. However, the modifications made to the motorcycle’s tyres and front fork would have impacted on its manoeuvrability and handling and could have reduced Mr Ridgway’s capacity to correct the motorcycle to avoid the accident.

The background On 25 February Mr Ridgway participated in a charity motorcycle ride. He rode the motorcycle.

There were an estimated 100 motorcycles participating on the ride. The group started from the Burnie Yacht Club at 10.30 am before riding west along the Bass Highway to the Murchison Highway and then through the Hellyer Gorge arriving in Waratah for a lunch stop. After lunch the ride resumed and travelled toward Cradle Mountain along Belvoir Road, through Moina heading toward Wilmot on Cradle Mountain Road.

Mr Ridgway was dressed in full protective clothing and was wearing a helmet. He was riding with Mr Williams, and they were positioned toward the front of the group. Mr Williams had ridden with Mr Ridgway throughout the day and at the time of the accident Mr Williams was riding his motorcycle directly behind Mr Ridgway. Mr George Schynol was also on the ride and was behind Mr Ridgway and Mr Williams. Mr Schynol had a GoPro fitted to the front of his motorcycle which captured the ride generally and specifically Mr Ridgway’s accident.

4 It was fitted with a 120/70 of 21 inch diameter tyre in the front rather than a 120/70 of 17 inch diameter and a at 300/35 of 18 inch diameter tyre rather than a typical 180/55 of 17 inch diameter at the rear.

5 Tasmania Police Subject Report 21 May 2023 p6.

6 Tasmania Police Subject Report 21 May 2023 p6.

7 Affidavit of Kurtus Williams sworn 25 March 2023 p1.

The environment Cradle Mountain Road, between Moina and Wilmot, is a two-lane road that runs in a generally north to south orientation. The road is constructed of bitumen and is subject to a speed limit of 100km/h. The north and south bound lanes are separated by double broken white lines.

The road has a painted edge line on each side with a 0.4 metre sealed verge on the north bound lane and a 0.8 metre verge on the south bound lane. Plastic guideposts were located at regular intervals on both sides of the road. Measured from edge line to centre line the north bound lane was 2.9 metres wide and south bound lane 3 metres wide.

The stretch of roadway at which the accident occurred had an approximate 8-degree downward gradient in the direction of Mr Ridgway’s travel. The corner at which he lost his line is described as a “moderate right hand bend”.8 At the time of the accident the weather conditions were clear.

The accident Mr Schynol’s GoPro footage shows Mr Ridgway riding his motorcycle and losing the “line” of a corner travelling wide on the road and entering the oncoming, southbound lane. This may reflect a loss of concentration at that time, encountering something on the roadway or a difficulty handling the motorcycle due to its modifications as outlined earlier.

After the accident Mr Ridgway was conscious. He told Mr Williams that as he was driving through a downhill right-hand corner the front wheel of his motorcycle hit a small rock in the centre of his lane and as a result he lost control and travelled off to the left hand side of the road which caused him to come off the bike, hitting his chest on the handlebars before landing in the blackberry bushes. He repeated this version of events to Ambulance Tasmania (AT) paramedics when being transferred from the scene to the Northwest Regional Hospital (NWRH) and to Ms Haddow when he was at the NWRH.

On arrival at the accident AT paramedics found Mr Ridgway on his back approximately 5 metres from the road in blackberry bushes. His helmet had been removed and he was complaining of chest pain, was pale and short of breath. Given the need for Mr Ridgway’s timely extraction they departed the scene with him prior to the arrival of Tasmanian Police and conveyed him to the NWRH. Subsequently officers from traffic crash investigation and forensic units of Tasmanian Police attended the accident scene and undertook an investigation as to its cause.

8 Affidavit of Senior Constable Barnard sworn 21 May 2023 p4.

The motorcycle was travelling in a northerly direction toward Wilmot when the accident occurred. Tyre marks were evident at the point at which the motorcycle came to a stop at the blackberry bushes on the western side of the road and extended 44 metres south from that point along the grass verge of the roadway. The marks were consistent with the wheels of the motorcycle rolling indicating that it is unlikely that the motorcycle was under braking for that distance. Based on his examination of the accident scene the traffic crash investigator, Senior Constable Barnard, concluded that Mr Ridgway rode wide at the exit of the corner, drove off the road surface, along the grass verge without braking, struck a guidepost before the motorcycle entered a culvert throwing him off into blackberry bushes.9 These conclusions are supported by the movements of Mr Ridgway’s motorcycle as shown on the GoPro footage and I accept them as an accurate description of the movements of the motorcycle leading up to the accident.

The GoPro footage also allows for a calculation to be made of the speed of the motorcycle by calculating the time it takes for the motorcycle to travel a defined distance as shown in the vision. This calculation identified the speed of travel of the motorbike as approximately 56 km/h at the time it left the roadway. This accords with estimates given by witnesses who assessed Mr Ridgway’s speed at the time of the accident as approximately 50 km/h. This speed fell well below the speed limit relevant to that stretch of roadway. I find that speed was not a cause of the accident.

I further find that neither alcohol nor drug use were causative of the accident. Whilst at the NWRH a blood sample was taken from Mr Ridgway and tested for the presence of substances in his blood which may have impacted negatively on his capacity to operate the motorcycle.

That testing did not detect the presence of any substance than medication administered to him by AT paramedics following the accident.10 The question remains as to why Mr Ridgway, an experienced rider of motorbikes, rode wide on the corner, onto the verge and into the culvert. Mr Ridgway’s explanation for the accident was that he had hit a stone on the roadway. Mr Williams who was following directly behind Mr Ridgway believes that he saw the front wheel of Mr Ridgway’s bike hitting a stone. He is “sure” that he saw a rock “fly out from under the bike”.11 Mr Schynol, who had two motorcyclists between himself and Mr Ridgway, did not observe any rocks on the road surface and attributed the accident to driver fatigue noting that by the time of the accident the group had been travelling for over an hour without a stop and Mr Ridgway’s driving behaviour, specifically his 9 Affidavit of Senior Constable Barnard sworn 21 May 2023 p4.

10 Certificate of analysis of blood sample by Mr McLachlan-Troup dated 28 April 2023.

11 Affidavit of Kurtus Williams sworn 25 March 2023 p2.

failure to brake as the motorcycle went wide and attempt to steer to get the motorcycle back onto the roadway were as if he was “oblivious to where he was and what was happening”.12 Senior Constable Barnard is an experienced motorcycle rider. He has been riding motorcycles since 1991. From 2006 he has worked as a police motorcyclist and as a police motorcycle instructor since 2017. He is trained in traffic crash investigations. He has reviewed the GoPro footage of the accident and makes the following observations:

1. Three motorcycles travelling in front of Mr Ridgway negotiated the corner without incident;

2. Mr Ridgway did not take the ideal line when entering the corner and should have been a further metre to the left which would have allowed him to take the corner in a more sweeping arc;

3. Mid corner Mr Ridgway’s right foot is seen making an unusual movement on the foot peg which could reflect the moment he ran over something;

4. After starting to run wide Mr Ridgway appears not to do anything to tighten up his line either by leaning his upper body off the motorcycle or applying some rear braking; and

5. The brake light on the motorcycle did not illuminate confirming that Mr Ridgway did not apply braking to the motorcycle prior to impact.13 After the accident Mr Ridgway consistently stated that he had run over a stone causing him to lose control of his motorcycle. Mr William, riding directly behind observed Mr Ridgway to drive over a stone. The fact that three motorcyclists safely negotiated the curve before him suggests no more than the lines they took into the curve did not bring them into contact with the stone. Constable Barnard considers that the line taken by Mr Ridgway into the corner was not ideal. As such, it was likely not the line taken by the motorcyclists that had preceded him.

Mr Schynol, being two motorcyclists behind Mr Ridgway, may not have been able to observe the stone particularly as, given its description by Mr Ridgway to Ms Haddow, it was small.14 Movement of Mr Ridgway’s foot as shown on the GoPro footage is consistent with him running over something. In light of these matters I find that the cause of the accident was Mr Ridgway riding over a stone as he negotiated a corner on Cradle Mountain Road between Moina and Wilmot. I further find that given the modifications made to the motorcycle as previously outlined, Mr Ridgway’s capacity to manoeuvre the motorcycle in response to running over the stone in such a way as to avoid the accident was significantly hampered. In addition, fatigue as 12 Affidavit of George Schynol sworn 5 April 2023 p2.

13 Tasmania Police Subject Report 21 May 2023 p8.

14 Affidavit of Joanne Haddow sworn 28 April 2023 p2.

observed by Mr Schynol may also have been a factor in the lack of any significant remedial response by Mr Ridgway to the movements of the motorcycle after running over the stone.

Mr Ridgway’s post-accident medical treatment and care Mr Ridgway was transported by Ambulance Tasmania to the Northwest Regional Hospital (NWRH). He was at that time in a critical condition having suffered left rib and right wrist fractures, a haemothorax and lacerations to his liver and pancreas.

Mr Ridgway was accommodated in the intensive care unit of the NWRH overnight before he was transferred to the Royal Hobart Hospital (RHH) by air the following morning. His condition deteriorated. At the RHH he was ventilated and underwent exploratory laparotomy on 27 February 2023 and a pancreatic laceration with pancreatic necrosis was identified. He was returned to theatre on 28 February 2023 for a “re-look”,15 adjustment of drains, peritoneal lavage and abdominal closure. Mr Ridgway’s post-surgical care was at the intensive care unit of the RHH where he remained until 9 March 2023. He was ventilated until extubated on 7 March 2023.

Mr Ridgway was transferred from the intensive care unit to a ward at RHH on 9 March 2023.

He was making a “good recovery”.16 On the evening of 15 March 2023 he is described in the nursing records as “alert and orientated to place and person”.17 He was watching television in his room with Ms Haddow and a friend. Mr Ridgway consented at that time to the routine taking of blood by a nurse and during the procedure is described as appearing “anxious”.18 After the procedure Mr Ridgway was noted to be “not right”.19 He became unresponsive, nursing staff activated the emergency bell, flattened the bed, and commenced cardiopulmonary resuscitation. Mr Ridgway was unable to be revived.

Following his death Mr Ridgway was examined by forensic pathologist, Dr Christopher Lawrence MB BS FRCPA. In his opinion Mr Ridgway’s death resulted from a pulmonary thrombo-emboli20 due to pancreatic contusion and necrosis suffered in the motorcycle accident as a result of handlebar impact.21 I accept that opinion and find accordingly. There are no issues regarding the treatment and care at the RHH.

15 RHH medical records.

16 RHH medical records.

17 RHH medical records.

18 RHH medical records.

19 RHH medical records.

20 Clot that has travelled to and blocked a blood vessel in the lung.

21 Opinion of the forensic pathologist, Dr Christopher Lawrence.

Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Gavin Ridgway; b) Mr Ridgway died as a result of pulmonary thrombo-emboli due to pancreatic contusion and necrosis due to, or as a consequence of, a single motor bike collision; c) Mr Ridgway’s cause of death was pulmonary thrombo-emboli; and d) Mr Ridgway died on 15 March 2023 at Hobart, Tasmania.

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

• The Police Report of Death for the Coroner;

• The Hospital Report of Death to the Coroner;

• The Tasmanian Police Subject Report;

• Affidavits as to identity and life extinct;

• Opinions of the forensic pathologist, Dr Christopher Lawrence;

• Certificate of analysis of blood sample by Mr McLachlan-Troup dated 28 April 2023;

• Tasmanian Ambulance report;

• North West Regional Hospital medical records;

• Royal Hobart Hospital medical records;

• Tasmanian Family Medical – Southside Family Medical records;

• Affidavit of Joanne Haddow sworn 28 April 2023;

• Affidavit and GoPro footage of Mr George Schynol 5 April 2023;

• Affidavit of Mr Kurtus Williams sworn 25 March 2023;

• Affidavit of Constable DePaoli sworn 3 May 2023;

• Affidavit of Constable Wotherspoon sworn 30 March 2023;

• Affidavit of Senior Constable Barnard sworn 21 May 2023; and

• Affidavit of Mr Philip Evans sworn 17 April 2023.

Comments and Recommendations I extend my appreciation to investigating officer Constable Hayden Barnard for his investigation and report.

The circumstances of Mr Gavin Ridgway’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 Ridgway.

Dated: 8 July 2025 at Hobart, in the State of Tasmania.

Leigh Mackey Coroner