Finding into death of Glenn Andrew Fisher

IN THE CORONERS COURT OF VICTORIA AT SALE Court Reference: COR 2012 000683

FINDING INTO DEATH WITHOUT INQUEST

Form 38 Rule 60(2) Section 67 of the Coroners Act 2008

I, Fiona Hayes, Coroner having investigated the death of Glenn Andrew Fisher

without holding an inquest:

find that the identity of the deceased was Glenn Andrew Fisher born on 7 July 1982

and the death occurred on 19 February 2012

at McLoughlins Beach

from:

1 (a) Consistent with drowning

Pursuant to section 67(2) of the Coroners Act 2008, I make findings with respect to the following circumstances: . ;

Glenn Fisher was aged 29 years when on 19 February 2012, he met up with his workmates for a day’s fishing at McLoughlins Beach, on the 90 Mile Beach in East Gippsland.

Mr Fisher was employed by Indigenous Designs and together with his workmates, met at their Morwell workplace before all driving to McLoughlins Beach, where they arrived at the carpark at approximately 10.30am, Mr Fisher drove there, with Mr Troy Webber, as a passenger, who provided a statement for the purposes of this investigation. They parked in Car Park 1, which is for the general public. Car Park 2 is reserved for those who are launching boats, which none of this party did.

From Car Park 1, the group crossed the pier and over the dunes, via a marked track and onto the ocean beach. At the beach, they turned right and walked up the beach towards McLoughlins Entrance. It took approximately 45 minutes to reach their site, where they unpacked their equipment, food and drinks, spread out and started to fish.

The day warmed up and Mr Webber states that, after a couple of hours, a decision was made to have a swim. Mr Fisher, Mr Webber and Michael, another of their group, entered the water “to float down current past where we were fishing’. Mr Webber stated “once we were past our rods we swam back in to shore at an angle and then walked back up to do it again, The current was quite strong although I didn’t find it hard to swim in, it was certainly strong” They decided to repeat the

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manoeuvre, but on this occasion, Mr Fisher was observed to go about 10m further out into the water. His friend, Mr Webber exited the water and looked for Mr Fisher. He initially saw Mr Fisher still out in the water and he did not appear to be in any trouble. Mr Webber then thought that he saw Mr Fisher try to swim over to the other side of the entrance and it appeared that he was nearing the shore on that side. When he next looked, Mr Fisher was in the breakers, where the ocean meets the inlet, Mr Webber had not seen Mr Fisher in distress, but he raised the alarm at this point. Mr Fisher was not seen from that point on.

Emergency services were notifed as quickly as possible but there was difficulty getting mobile phone coverage on the beach. Hence, it took some time to get sufficient coverage to make that call.

There was a very immediate and significant response by emergency services, which included Victoria Water Police, Port Albert Coast Guard, Woodside Life Saving Club, Westpac Life Saver Rescue Helicopter and the Victorian Helimed and local police units.

A number of craft were deployed. The Coast Guard searched the area outside the breaking waves.

The Surf Life Saving dinghy searched the waters inside the breakers. The Helimed helicopter deployed sea dye at the entrance to ascertain and follow the current to where Mr Fisher might have been taken. Using this method, Mr Fisher’s position was identified by the Helimed helicopter, which in turn directed the Port Albert Coast Guard to Mr Fisher. Tragically, Mr Fisher was deceased at that time. Mr Fisher was brought to shore and was received at the Port Albert Coast Guard Headquarters at approximately 5.30pm.

Mr Fisher was wearing denim shorts, which would have been heavy when wet and difficult to swim in.

The conditions applicable at McLoughlins Beach, on that day, were described by attending emergency services personnel as very serious. The tide timetables for that date indicate that McLoughlins Beach inlet experienced a very high tide that day, which at the time that Mr Fisher was swimming, was retreating to the ocean. The height and speed of that ebbing tide made conditions treacherous at the entrance, the point at which Mr Fisher and his friends were jumping in to catch the tide. Terry Young, Deputy Commander of the Port Albert Coast Guard, who attended on the day, stated that he knew the area very well — “It is a very dangerous spot with a very strong outgoing tide. On this day I remember it was the worst conditions we had for the entire month. The outgoing tide was going at 8 knots which is extremely fast in the circumstances. The strongest swimmer in the world couldn’t swim against that current”. Very similar sentiments were voiced by Graeme Hurrell, Emergency Service Officer and Life Member of the Woodside Life Saving Club.

Mr Hurrell operated the inflatable rescue boat during the search for Mr Fisher. He remembers the “tidal currents being extremely strong on this day”, with waves at half'a metre to a metre at the entrance.

It appears that Mr Fisher ventured further out into the water than his colleagues, probably where the current was stronger. Once caught in that current, hc would have been unable to swim against it and would have had no ability to prevent being swept into the maelstrom of the breakers and out beyond.

The emergency services who attended on the day were very quickly on the water and were presented with very treacherous conditions. The turbulence at the entrance made it difficult to predict the path that Mr Fisher followed. Hence the deployment of the sea dye, which viewed by the helicopter and those on the water, outlined the course of the current, which led them to Mr Fisher.

A view of the scene was conducted which greatly assisted my understanding of the site where Mr Fisher lost his life, but also the seascape in which Mr Fisher so quickly lost control and was overcome, The conditions at the entrance were so tumultuous that the water would have appeared

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very fast flowing and choppy. However, to those not familiar with such conditions, or with the power of the outgoing tide, the risk presented may not have been understood.

McLoughlins Beach is a popular boating and fishing spot. However, those who are familiar with the entrance know that there can be very strong currents, particularly at the entrance. As previously mentioned there are two car parks which allow access to the beach and boating ramp. Car Park 2 is provided for those who are launching boats. This car park is governed by the Ports Authority and there is an array of signage for those entering the water by boat. Those signs refer to the strength of the current and the dangers posed. The signage there located is of varying age and reliability. A review of that signage should be undertaken to ensure its consistency and relevance.

However, for those who do not fish by boat, but who cross via the pier to the beach, the signage present at the time Mr Fisher’s death was significantly less informative than that in Car Park 2.

At Car Park 1, the signs do not give any indication of the dangers of swimming either on the beach or at the entrance. The absence of signage was a significant concern for emergency service personnel, who submitted that there needs to be new warning signs erected to alert beach goers to the dangers associated with the water at this location.

Since Mr Fisher’s death, new signage has been erected by Parks Victoria on land within its jurisdiction, namely, where pedestrians who are on their way to the beach walk from the pier onto the path which takes them to the beach. The signage there erected by Parks Victoria gives the appropriate warnings about dangerous currents and the absence of life guards except for certain limited times of the year.

However, there is an additional need for appropriate warnings to users of the beach about the dangers of the currents, in terms similar to those of Parks Victoria. In my view, there should be additional signage erected in Car Park 1. This signage should point out the dangers associated with the beach as well as the entrance.

An autopsy: was conducted by Dr Sarah Parsons, Pathologist at the Victorian Institute of Forensic Medicine, who formulated the cause of Mr Fisher’s death as “consistent with drowning’. Mr Fisher had a medical history which included well-controlled epilepsy stemming from a previous neurological condition. Dr Parsons posited that it was possible that Mr Fisher may have lost consciousness for other reasons, including an epileptic seizure or a cardiac arrhythmia, but she concluded “in this case the circumstances and subtle autopsy findings strongly suggest drowning.”

Toxicological analysis revealed the presence of methamphetamine and amphetamine at 0.3mg/L and 0,1mg/L respectively, in addition to his prescribed medication. None of these were identified at toxic level. No alcohol was detected. ‘

The presence of amphetamines is as a result of having taken methamphetamines, the former being a derivative of the latter, The levels of methamphetamine detected are indicative of use within a recent timeframe, most likely that day, but perhaps the day before. It is difficult to know what, if any effect, this drug had on Mr Fisher’s judgment, and that would depend on when he had taken the drug, the amount taken and any tolerance to it. However, it is very possible that his judgment was impaired in relation to the calculation of risk.

A consistent issue raised by emergency services personnel in this investigation was the difficulty in contacting emergency services from the beach. It is a remote location and it took approximately 45 mins for those assisting Mr Fisher to get a signal sufficient to make the call.

Although remote, McLoughlins Beach is regularly used by beachgoers and has a resident or holiday population closeby. I support the need to investigate whether telecommunications to emergency

services can be improved. Options include the installation of Emergency Response Beacons, which establishes a two way communication system between the location and triple zero operators, Other

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options include remotely operating camera monitoring systems and emergency markers. If so, an earlier response may save future lives.

It remains to commend those emergency personnel who put their lives at risk in very treacherous conditions to rescue Mr Fisher. In addition, the commitment of such significant air and sea resources, with speed and efficiency greatly reduced the amount of time needed to locate Mr Fisher.

Iam indebted to each of the following for conducting the view on the water at McLoughlins Beach, which provided an important insight to the conditions which Mr Fisher experienced — Sergeant Stafferton, S.C. Anderton, Graeme Hurrell and Terry Young. I am grateful to each for their time, experience, knowledge and ongoing commitment to water safety and rescue.

Glenn Fisher was a much loved son, brother and friend. Never afraid of a challenge, he was active in life and had much experience, while fishing, on shore and on the sea. However, strong and healthy though he was, he was overpowered by the very treacherous waters at the McLoughlin’s Beach entrance,

I find that Mr Fisher drowned in the circumstances outlined above.

RECOMMENDATIONS

Pursuant to section 72(2) of the Coroners Act 2008, I make the following recommendation(s) connected with the death:

1. That the Wellington Shire Council erect signage at Car Park 1 to warn members of the public about the dangers of the tidal currents at the beach and entrance and about the dangers of swimming at the beach or at or near the entrance.

2. That Gippsland Ports review signage in Car Park 2 its accuracy, consistency and relevance.

3. That the Emergency Services Telecommunications Authority, Victoria, investigate the options for the provision of communications to emergency services in case of an emergency, at points closer to the beach.

Pursuant to rule 64(3) of the Coroners Court Rules 2009, I order that the following be published on the internet:

All of the above

I direct that a copy of this finding be provided to the following: Surf Life Saving Victoria

Senior Constable Luke Anderton

Captain Tim Hungerford-Morgan, Harbour Master, Gippsland Ports Parks Victoria

Wellington Shire Council

Emergency Services Telecommunications Authority, Victoria

Sergeant Adrian Stafferton, Glen Waverley Police Station

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Mr Terry Young, Port Albert Coast Guard, Victoria Mr Graeme Hurrell, Woodside Surf Life Saving Club

Signature:

Fiona Hayes Date: 3 December 2013

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