Deceased
Tristan Edmond Cosgriff
Demographics
18y, male
Coroner
Coroner Heather Spooner
Date of death
2010-03-25
Finding date
2013-02-22
Cause of death
Multiple injuries secondary to motor vehicle accident
AI-generated summary
An 18-year-old male died from multiple injuries sustained in a motor vehicle collision when his vehicle veered left off Plenty Road, Mill Park and struck a tree. The vehicle was travelling faster than the speed limit, the driver was not wearing a seatbelt, and there was no evidence of braking or steering input before impact. Toxicology was negative for alcohol and drugs. The coroner found insufficient evidence to support findings of involvement by another vehicle, intentional self-harm, or contributory road infrastructure factors. The collision likely resulted from driver distraction causing the vehicle to veer left, followed by loss of control. The coroner commended VicRoads and TAC for funding safety improvements including roadside hazard removal, sealed shoulders, and wire rope barriers along this arterial road, where multiple tree-strike fatalities had occurred.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Court Reference: COR 201001 141
Form 37 Rule 60(1) «Section 67 ofthe Coroners Act 2008
Inquest into the Death of: Tristan Edmond COSGRIFF
Delivered On: 2 te 1 22 February 2013
Coroners Court of Victoria
Delivered At Level 11, 222 Exhibition Street Melbourne 3000 , Hearing Dates: woe 44 August 2012 Findings of: Coroner Paresa Antoniadis SPANOS Representation: . . ; ; MrJ ames Donald COSGRIFF, the deceased’s brother,
' attended the inquest on behalf of the COSGRIFF family.
. Police Coronial Support Unit: Leading Senior Constable Kelley RAMSEY, assisting . , the Coroner :
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J, PARESA ANTONIADIS SPANOS, Coroner,
having investigated, the death of TRISTAN EDMOND COSGRIFF
and having ‘hneld an inquest in relation to this death
on.14 August 2012 at Melbourne
find that the identity of the deceased was ‘TRISTAN EDMOND COSGRIFF : born on 20 April 1991
and that the: death occurred on 25 March 2010 .
at Plenty Road, Mill Park, Victotia 3082
from:
2,
1(a) MULTIPLE INJURIES 1 (b)’ MOTOR VEHICLE ACCIDENT
— in the following circumstances:
Tristan Cosgriff was a young man of eighteen years who resided with his family in Mill Park,
“had a casual job and was stuidying Accounting at Northern Metropolitan Institute of TAFE : (XIMIT) after completing his ‘secotidaty schooling at Parade College, Bundoora. According to
his family, Tristan had been a successful junior footballer, played basketball successfully at competition level and was a popular and well-regarded young man who maintained a healthy
lifestyle and had never given them cause for concern regarding his behaviour. According to
his medical records, Tristan enjoyed good physical health, and had not presented with any
: history. of depression: or any-other niexital illness.
On 25 March 2010, Tristan attended « one of his regular classes at, NMIT finishing at about 1230 hours. His movements. ‘thereafter are unknown until about 1355 hours when he was parked: ot ‘thé ‘western roadside reserve of Plenty Road, Mill Park, some 100 metres north of
Childs Road. The vehicle was a Ford sedan registered in his father’s name, and Tristan was
parked near the scene of a multi-victim motor vehicle collision that occurred two months ©
a Paragraphs j & % are a gummaty af facts that weié ‘é uncontentious, and provide a context for those circumstances
which were contentious and will be discussed in some detail from paragraph 14 onwards.
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earlier and had achieved a level of notoriety, not only locally but more broadly due to media
reporting.”
wearing a seatbelt.”
“4 Neat Rivergum Drive, Tristan’s vehicle veered left, leaving the roadway, travelling over the gravel shoulder onto the grassed roadside reserve, and colliding head-on with a large tree.
The impact caused his vehicle to spin clockwise, roll and comie to rest on its roof, against a paling fence. Despite the immediate assistance of Ms Hatzis, and Jeanine Benton, an off-duty ‘police officer who lives nearby and helped pull Tristan from the vehicle, and the attendance of "ambulance paramedics and’ other ‘eiétgency services responders a short time later, Tristan
sustained fatal injuries and died at the scene.
5.- The coronial investigation of Tristan’s death was constrained by the absence of other witnesses’ to the’ collision proper. "The only additional evidence relevant to the collision was the physical evidence at the scene, and the expert evidence of Sergeant Peter Bellion from the Specialist Collision Services Unit of the Major Collision Investigation: Group of Victoria Police. Some of the circumstances raised the possibility that Tristan had intentionally taken his.own life. ) ,
. hurtful, could be addressed openly in a public hearing. They also raised concerns about
aspects of road infrastructure, and the degree of uncertainty around the circumstances in
: ? See Coroner Spooner’s findings regarding the death of Steven Johnstone and Ors delivered on 21 December 2012
3 Statement of Ms Anna Hatzis dated 19 May 2010, Exhibit “A”, Her evidence will be canvassed in more detail below.
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which the collision occurred.’ - My decision to proceed to inquest was very much in response to ‘the family’s request.” ‘Asa general proposition, a death in such circutnstances would not necessarily otherwise warrant an inquest, as part of the coronial investigation, even if some of
the circumstances remained unclear.
its forensic significance and the interésts of narrative clarity.
, oceutted.*- The cause of “death refers to the medical cause of death, incorporating where possible the mode ot mechanism of death, For coronial purposes, the circumstances in which
death occurred refers to the context or background and surrounding circumstances, but is
4 Letter from Mr Brendan Cosgriff dated 16 Seplember 2011. Rv Hemsworth [2009] NIOB 33 at [35]-f. 36} and Re Ramsbottom [2009] NIQB 55 at [17}- While a coroner cannot investigate every rumour or suspiciou, the coroner must not prematurely conclude that rumours or suspiciouns cannot hope to be confirmed. Instead, the coroner must assess whether there is a reasonable evidentiary basis to warrant investigation and, if so, call relevant evidence to investigate the rumour or suspicion,» - . . :
. § See section 521) of the Coroners Act 2008, hereinafter referred to as the Act.
6 From the commencement of the Coroners Act 2008 (the Act), that is 1 November 2009, access to documents held by the Coroners Court of Victoria is governed by section 115 of the Act. ~ .
7 The Coroners Act 2008, like its predecessor the Coroners Act 1985, requires certain deaths to be reported to-the ”
coroner for investigation. Apart from a jurisdictional nexus with the State of Victoria the definition of a reportable .
death in section 4 includes deaths that appear. “to have been unexpected, unnatural or violent or to have resulted,
directly o¥ indirectly, from accident or injury” and the death of a person who immediately before death was a patient . within thé meaning of the Mental Health Act 1986". . :
8 Section 67(1) of the Coroners Act 2008. All vefererices which follow are to the provisions of this Act, unless
otherwise stipulated. ;
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confined to those citcumstances sufficiently proximate and causally relevant to the death and
not merely all circumstances which mi ght form part of a narrative culminating in death.”
' 9, The broader purpose of coronial investigations is to contribute to the reduction of the number of - preventable * ‘deaths through the. findings of the investigation and the making of recommendations by coronets, generally referred to as the prevention role. 10 Coroners are also empowered to report to the Attorney-General on a death; to comment on, any matter connected with the death they have investigated, including matters of public health or safety and the administration of justice; and to make recommendations to any Minister or “public .
statutory: authority on any inatter connected with the death, including public health or safety or the administration of justice.” ' These are effectively the vehicles by which the prevention role
may be advanced,’
advised that Tristan’s death could be reasonably attributed to multiple injuries secondary to a
9 ‘This is the effect of the authorities - see for example Harmsworth v The State Coroner [1989] VR 989; Clancy v West (Unreported 17/08/1994, Supreme Courtof Victoria, Harper J.)
© The “prevention” role is iow explicitly ‘articilatéd i in the Preamble and purposes of the Act of the Coroners Act 1985 where this role was generally accepted as “implicit”. :
un See sections 72(1), 67(3) and 72(2) of the Act regar ding reports, comments and recommendations respectively.
v See also sections 73(1) and 72(5) of the Act which requires publication of coronial findings, comments and | recommendations and responses respectively, section 72(3) and (4) which oblige the recipient of a coronial recommendation to respond within three months, specifying a statement ofa action which has or wil be: taken i in relation to the recommendation, :
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12:
43,
motor vehicle accident:. In terms of the nature and extent of the injuries, Dr Bedford advised that PMCT showed fractures of the right distal humerus, radius and ulna (the main bones of the right arm), sight femur (right thigh bone), a fracture dislocation of the right ankle and,
significantly, skull fractures.”
Toxicological analysis of a post-mortem blood sample, also undertaken at VIFM, detected no
ethanol (alcohol) or other common drugs or poisons. There is thus no evidence to suggest that Tristan’s ability to drive a motor vehicle, or his cognition, were impaired by substances to any extent, In light of the main focus of the coronial investigation of Tristan’s death which was to understand what may have caused or contributed to the motor vehicle accident (ot more
properly “collision”), this isa significant “negative” finding."4
I find that the medical cause of Tristan’s death was multiple injuries secondary to _a motor
vehicle accident.
The. focus of the. coronial investigation of Tristan’s death was on the motor vehicle accident itself - the role played by any other driver or vehicle, the contribution of prevailing weather conditions or any aspects of road infrastructure, and whether or not the accident -was in fact not accidental but intentional. These issues were either explicitly raised by the family in correspondence with the Court and/or in their request for an inquest, or were implicit in the
cir cumstances::
The family raised the possibility of another driver being involved in the collision, specifically ;
a driver turning right from Rivergum Drive into Plenty Road to join vehicles travelling north,
15 ‘Phe inference was that someone
that is in the same direction as Tristan and Ms Hatzis.
could have done so unsafely causing Tristan to veer left and lose control of ‘his vehicle.
‘Senior. Constable Cushen ‘verified ihat-such a turn would be legal, as the intersection had been
configured to allow for a tight tum from Rivergum Drive into Plenty Road. ie However, Ms
Hatzis, who was travelling in the left lane immediately ahead. of Tristan, did not recall seeing
2 pr Bedford's “Medical Examination Repoit is part of Exhibit “I” the balance of the brief.
: uM sé paragraph. XX and following ‘below where thé circumstances of the collision are discussed in some detail.
‘5 Transcript page 3.
, Transcript page 11.
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any vehicles in the’ lane to her right, nor could she recall seeing any vehicles entering Plenty Road from Rivergum Drive.’7 Police found no physical evidence at the scene to suggest that any other vehicle was involved inthe collision, and no witnesses came forward to say that
Another-vehidle was involved.8 *
16.. In terms of overall driving conditions at the time of the collision, traffic was light and visibility :
“17,
19,
was excellent. It was broad daylight on a fine day, when the sun was high and to the. west, posing no hindrance to, the visibility of drivers travelling north. There was no suggestion of .
any physical obstacle. to visibility, or that the collision occurred in other-than perfect driving
conditions.’
In terms of road infrastructure and the physical environment at this location, Plenty Road is an
’ divided arterial road constructed of a bitumen spray and aggregate seal, with provision for two
marked traffic lanes in either direction, separated by a wide, raised media strip bordered by
conereté- Ketbing. “The northern caitiageway has a straight north-south alignment and a slight
downhill grade. Immediately to the west of the marked northbound lanes is a two metre wide sealed bitumen shoulder, further west is a gravel shoulder, followed by a downward sloping © grassed verge, tree plantings, further grass, an open drain, a concrete path, more gtass and
residential fencing.”
At inquest, a number of witnesses thought that the gravel shoulder posed a driving hazard and raised the possibility of a loss of traction/control. Witnesses also expressed concerns that the
downward slope of the grass verge was steeper than it looked from the photographs in the
" brief, and may have contributed. some momentum to Tristan’s vehicle after it left the roadway
; and thus contributed.to ihe collision.”
Apart from these hypotheses of lay witnesses, there was the expert evidence of Acting Senior
Sergeant Peter Bellion from the Specialist Collision Services Unit of the Major Collision
7 Bxhibit A” and transcript pages 45:
'® Transcript page 20, where it is clear that the “scene” for these purposes encompasses the intersection of Rivergum Drive and Plenty Road :
ia Exhibit “A”, transcript page 6, statement of Leading Senior Constable David Mair and the photos he took about one and a half hours after the collision which are part of Exhibit “I” the balance of the inquest brief. :
20 Exhibit “C” and LSC Mair’s statement and photos in Exhibit “F’.
1 "Transcript pages:
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Investigation Group who undertook ‘a collision reconstruction drawing on his training, study,
experience and specialised knowledge.” The conclusions in his statement were that —
e the physical evidence indicates that the vehicle was travelling faster than the speed limit;
_@ there appeared to be no attempt to brake prior to impact with the tree; -
@ there appeared to-be 1io ‘atteript to steer the vehicle once it left the roadway to try to avoid impact with the tree;
e the principle impact force was aligned with the driver’s seat; and.
e the driver was not wearing a seat belt.
Acting Senior Sergeant Bellion expanded on his statement and conclusions at inquest2? On
my reading of his evidence, he did not materially modify his conclusions. Referring to the
40.9 metre distance between the point where the vehicle entered the gravel shoulder and. the impact with the tree,”* he reiterated the view that, even at speed, there was enough opportunity for Tristan to manoeuvre around the tree, so as to avoid impact altogether. While he testified
that Tristan appeared to have taken a line between a bus shelter and a pole situated on- the
roadside ‘reserve, appatently ‘steering towards the tree, he conceded that as a relatively
inexperienced young driver, Tristan may not have been well-equipped to take sudden evasive
. action, and/or may have panicked. By reference to Ms Hatzis evidence, he conceded that the
initial manoeuvre whereby the vehicle left the roadway may have resulted from the distraction
‘associated with leaning down towards the left unrestrained, succumbing to the tendency to
steer'-to the left. The apparent absence of braking or steering input from the driver, also raises
the possibility of a blackout or other natural disease process, which he also conceded was a-
possibility consistent with the physical evidence found at the scene.”
Tristan’s family provided details of-his general good character and relied on the absence of -
_any prior mental. illness or noted.changes in behaviour or demeanour, relevant to: both the
? Details of his formal qualifications and extensive experience are contained in his statement, Exhibit “C”.
See transcript from pages 20 and. following:
ey note that the tree was located 8,25 metres west of the left edge of the left northbound traffic lane and 6.25 metres
Tyanscript pages 27-28.
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unlikelihood that he would have been driving in an unsafe manner, and the unlikelihood that
he intentionally caused the collision in order taken his own life.
22, A ‘aumbet of Tristan’s friends provided statements and attended the inquest to testify.
Although somewhat nuanced, their evidence supports a finding that Tristan was a popular ‘well-adjusted young man who had a lot going for him. They saw nothing in his behaviour to suggest suicidality or to raise concerns for his safety, and were not aware of any significant issues in his life that might be troubling him. They thought Tristan may have had some family
; issues,. but nothing out of the érdinary. 29 They were familiar with his driving habits and considered him to be a safe driver, probably the best of the group, who was not known ‘to.
speed or to be a “hoon” on the road,”
distracting Tristan, shortly before he. left the roadway, Senior Constable checked his mobile
phone and’ found no evidence of incoming or outgoing calls or text messages for some houts
before the collision." Two of Tristan’s friends, Liam Hunt and Matt Ceri, thought that he could be distracted by the CD player or might try to change CDs whilst driving.” James
Cosgriff, Tristan’s older brother also gave evidence about this at inquest. He testified that the
vehicle had a six cD stacker and there was no need to change CDs while driving. Moreover, :
-as te spare’ CDs were kept in a storage place under the front passenger seat, whilst. it was possible, it would be too dangerous to reach for them while driving, and he couldn’t imagine
Tristan would do so.*”
. 24.. For completeness, I note that-although a relatively inexperienced driver, Tristan was familiar
with the vehicle he was driving and familiar with the general vicinity of the collision. I also
26 Statement of Mitchell Oliver, Exhibit “D” — “besides the family stuff that always happens in every family, there was nothing too major.” Statement of Matt Cerni, Exhibit “F” — “In rélation to any problems he might be having, he was sort of wanting to move out of home because his mum and dad were very sttict...But that was probably about it.” Statement of Hirsi Twomey, Exhibit “G” — “before we turned 18 and stuff, like his parents sometimes wouldn’t’ let him ~ come out with us. I don’t know if he had troubles with them or his parents were overprotective, like I don’t blame them, my parents are the saine.” Statement of Christopher Nave, Exhibit “Er — “I wasir’t aware if he had any issues at
27 See statements referred to above and statement of Liam Hunt, Exhibit “EB”. Also transcript pages 33-34, 37; 41, 44. .
28 Note that the vehicle ended on its roof arid sustained. significant crush damage/cabin intrusion. The mobile phone was handed to Sen Const Cushen by someone at the scene, so its precise location in the vehicle, prior to the collision, is unknown, Transcript page 8. ; : :
: : 9 Tixhibits “B’ and “F”, transcript pages 37, 39-40. ° _ Transcript pages 48-49. , howe
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note that mechanical inspection ‘of the vehicle after the collision revealed no mechanical faults
ot problems with could have caused or contributed to the collision.**
27,
The standard of proof for coronial findings of fact is the civil standard of proof on the balance
of probabilities with the Briginshaw gloss or explication.” [have applied that staridard to the
totality of the evidence available to me.
Having done so, | find that there is insufficient evidence to support a positive coronial finding”
that any other-vehicle was involved inthe collision, although the possibility cannot be sensible
._ excluded altogether: Nor does the weight of the evidence support a finding that any aspect of
road infrastructure or prevailing weather conditions caused or contributed to the collision, in
any meaningful sense.
I further find that there is insufficient evidence to support a positive coronial finding ‘that Tristan intentionally causes the collision in furtherance ofa plan or intention to take his own life: Whilst I accept ‘Actirig Senior Sergeant Bellion’s analysis of the physical evidence, and the inferences which can be drawn from that evidence, in my view, it is at least equally plausible that Tristan veered to the left and left the roadway whilst distracted, and thereafter.
simply lost control of his vehicle, in circumstances which would have challenged even more
experienced drivers. — -
Pursuant to section 67(3) of the Coroners Act 2008, I make the following comment(s) connected
with the death:
In the concluding’ paragraph ‘of his: statement, Acting Senior Sergeant. Bellion called for " VicRoads to investigate the installation of wire rope safety fencing along this stretch of Plenty
-Road as a priority.”
at t rayscript pages 47 and followin ig. Statement of, ;
Briginsticiw v Briginshdw (1938) 60 CLR. 336 e
sp at 362-363 - “The seriousness of an allegation made, the inherent
“unlikelihood of an occurrence of a given description, or the gravity of the consequences flowing from a particular finding, are considerations which must affect the answer to the question whether the issues had been proved to the reasonable satisfaction of the tribunal. In such matters “reasonable satisfaction” should not be produced by. inexact proofs, indefinite testimony, or indirect inferences...” . : .
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moineritum- and minimising the extent of injury and, of lesser concern, property damage.**
3, - At inquest, Ms Patricia Liew, VicRoads advised that the Traffic, Accident Commission (TAC) had agreed to fund a VicRoads’ proposal for improvements on a 2.5 kilometre. stretch of
; Meaty Road, between McKimmies Road and Centenary Drive, encompassing the ‘collision site.” ° The road safety. treatments, included i in the proposal involve the removal of roadside hazards (such as trees), the construction of sealed shoulders (on the median side) and the
installation of roadside barriers, both wire rope and fixed metal barriers.°°
4, ‘VicRoads and the TAC are to be commended for developing and funding the proposal
" respectively, thereby improving the safety of all road users at this arterial road location.
I direct that a copy of this finding be provided to: The family of Mr Cosgriff Senior Constable Jaclyn Cushen (#35316) c/o Epping Traffic Management Unit VicRoads Traffic Accident nisin , Shire of Whittlesea
Signature:
. PARESA ANTONIADIS SPANOS CORONER Date: 22 February 2013
3 «From a preventative measure in 1 Tew [sic] of this being the sixth death associated with cars strilcing trees off the left hand side of Plenty Road, Mill Park this year, I recommend that VicRoads investigate the installation of wire rope safety fencing along this:stretch of road as a priority.” Exhibit “C”.
4 Transcript page 59 and RTA Road Environment Safety Update No 24 issued March 2004, in Exhibit “T’.
35 Statement of Nial Finegan, Regisnal Directot, VicRoads dated 7 February-2012 in Exhibit “I”. This stretch of Plenty . Road alsa encompasses the: collision site where ihe: carlier multiple fatality collision occurred, See footnote 2 above. *
os Th anscript pages 56 and following where Ms Liew describes the proposed improvements.
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