Finding into death of Shane Kenneth Warrick

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2013 3795

FINDING INTO DEATH WITHOUT INQUEST

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

I, AUDREY JAMIESON, Coroner having investigated the death of SHANE KENNETH

WARRICK

without holding an inquest:

find that the identity of the deceased was SHANE KENNETH WARRICK born on 25 February 1975

and the death occurred on 26 August 2013

at 2057 Western Freeway, Rockbank, 3335

from: 1(a) MULTIPLE INJURIES

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

1. Mr Shane Kenneth Warrick was 38 years of age at the time of his death. He lived alone at the Sundowner Caravan Park (SCP), 2057 Western Freeway, Rockbank since May 2013.

2. On Sunday 25 August 2013, Constables Jamie Jordan and Kevin Shea of Melton Police attended Mr Warrick’s residence after he contacted Emergency Services reporting thoughts of harming his father. He was found in an agitated state and was transported to the Sunshine Hospital for psychiatric assessment pursuant to Section 10 of the Mental Health Act 1986 (Vic).

3. During the assessment by the Sunshine Hospital Emergency Crisis Assessment and Treatment Team (ECATT), Mr Warrick admitted to being a daily user of cannabis/tobacco and coffee

but denied alcohol use. He stated he felt socially isolated and was angry regarding his

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perceived mistreatment by his father. Mr Warrick spoke of occasional suicidal and homicidal ideas but adamantly denied any plan or intent to act on these thoughts. He was cooperative during the assessment and expressed a willingness to re-engage with mental health services.

He reported that he had recently stopped taking olanzapine, but was willing to consider recommencing. He was provided with a single dose in the Emergency Department and a further four tablets to recommence treatment over the following 24-48 hours pending further contact with the community treatment team. Mr Warrick’s thinking was assessed as somewhat impaired, but was directed to the future and potentially finding employment. The ECATT clinician confirmed his history and obtained further collateral information from Mr Warrick’s

sister-in-law, Mrs Sophie Warrick.

Mr Warrick was released later that day and returned to the SCP where the park manager spoke with him. Mr Warrick continued to appear agitated and revealed negative thoughts about

himself before his mood appeared to settle within one hour.

At approximately 10.00pm on 26 August 2013, a driver travelling in a westerly direction along the Western Freeway, Rockbank, in the left hand lane approaching the SCP observed a person wearing dark clothing with a hood over their head, standing on the solid white line painted on the road surface on the south side of the westbound lanes. As the driver approached the person, she observed them to be male. His actions appeared consistent with someone intentionally stepping out in front of her vehicle into the left westbound lane. The driver took immediate evasive action to avoid a collision and travelled a short distance before stopping

and contacting ‘000’.

About the same time that driver was contacting ‘000’, another driver travelling in the same direction along the Western Freeway in the right hand lane approached SCP, and was overtaking a prime mover, which was travelling in the left land. As this driver’s vehicle passed the prime mover at approximately 90km/h, Mr Warrick stepped into the path of the vehicle from the left side and the front of her vehicle struck him. The impact caused Mr Warrick to roll up onto the bonnet where his head impacted the windscreen, causing the windscreen to shatter. Mr Warrick came to rest on the grassed median strip to the west side of

the sealed crossover, approximately 20m west from the point of impact.

Emergency Services were contacted however attending Paramedics were unable to revive Mr

Warrick.

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At the time of the incident, it was dark and there were no streetlights. The road surface was

dry and the weather was fine.

The driver of the vehicle involved in the incident was a holder of a full and current Victorian

driver licence and returned a negative preliminary breath test result.

INVESTIGATION

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Associate Professor David Ranson, Deputy Director of the Victorian Institute of Forensic Medicine (VIFM), performed an external examination on the body of Mr Warrick, reviewed a post mortem CT scan and reviewed the Victorian Police Report of Death, Form 83.

Anatomical findings were consistent with the known mechanism of injury.

Toxicological analysis of blood and other bodily fluids retrieved post mortem identified the presence of presence of alcohol at a blood concentration of 0.16g/100mL,' benzodiazepine, olanzapine, tramadol and cannabis at a concentration suggestive of recent use. Associate

Professor Ranson ascribed the cause of Mr Warrick’s death to multiple injuries.

The circumstances of Mr Warrick’s death have been the subject of investigation by Victoria Police. Police obtained statements from Mr Warrick’s father, Mr Kenneth Warrick, Mrs Sophie Warrick, the SCP Manager, Sunshine Hospital Director of Clinical Services Dr David Fenn, the two drivers and the occupants of the relevant vehicle. Police made unsuccessful enquiries to locate further witnesses to the incident, or anyone that had contact with Mr Warrick immediately prior to the incident. Police have not been able to identify the truck

driver of the B-Double semi trailer.

The investigation revealed that Mr Warrick’s mother died when he was ten, and his long-term girlfriend died in 1999. He had told his father that he had been stabbed and sexually assaulted in the past. Approximately two weeks prior to his death, he told his father and sister-in-law

that he had been diagnosed with cancer.

Mr Warrick was last seen by his father at approximately 8.30pm on 26 August 2013, after

having spent some time with his son, who appeared agitated and intoxicated. The two had

' The legal limit for blood alcohol for fully licensed car drivers is 0.05g/100mL. BAL in excess of 0.15g/100mL can cause considerable depression of the central nervous system (CNS). Other drugs capable of depressing the CNS will increase the effects of alcohol.

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been to a shopping centre and Mr Kenneth Warrick observed his son to be behaving somewhat unusually, asking after various family members. Mr Warrick appeared to be in better spirits

when his father left him at the SCP.

Previous ECATT assessments of Mr Warrick have assessed him as being a heavy alcohol consumer, up to five litres of wine/spirits weekly, and to having a long psychiatric history, being previously diagnosed with paranoid schizophrenia, cannabis and alcohol dependence, drug-induced psychotic episodes, amphetamine intoxication and anti-social personality

disorder.

Mr Warrick had previously been an inpatient of the Werribee Mercy Psychiatric Service in 2004 and had contact with forensic psychiatric services whilst incarcerated at the Melbourne Assessment Prison in 2006 for burglary, arson and assault. After serving a three-month prison sentence, Mr Warrick was referred to the Werribee Mercy community psychiatric services, who were involved in his care between 2006 and 2008. Mr Warrick had further psychiatric admissions to the Alfred Hospital in 2011 and to Sunshine Hospital in 2012, after which he was referred to the Mid West community based psychiatric services for further review. He responded to treatment with antipsychotic medication olanzapine and was seeking assistance

to find stable employment.

The police investigation determined that the signposted speed limit for the relevant freeway section is 90kph westbound and 100kph eastbound. Vehicular traffic ranging from motorcycles to B-Double trucks are often reported tailgating, driving dangerously and

travelling well in excess of the posted speed limits.

The only entrance to the SCP is located directly off the Western Freeway and is the only residential or business location in Rockbank that has direct access onto the freeway instead of the use of a service road or similar. The SCP is accessed directly from the freeway by turning left off the freeway via the westbound lanes of the freeway, or by turning right from the eastbound lanes, crossing over the wide grassed median strip via a six metre wide sealed

crossover, then driving across the westbound lanes.

A give way sign is located at either end of the crossover for vehicles intending to cross over the westbound lanes to enter the caravan park or to turn right and merge into the westbound traffic. Vehicles needing to exit the SCP cross over the westbound lanes and the sealed

crossover and turn right into the eastbound traffic.

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There are two bus stops located on either side of the freeway. Sita Bus Services provides the service for this route, servicing Caroline Springs, Rockbank and Melton. This is the only bus service to operate in this area. Nearby public transport (V-Line) operates a train service from

the Rockbank Train Platform, approximately one kilometres from the scene.

The crossover area is not illuminated and bus passengers who require access the eastbound bus service/shelter from the SCP have to negotiate their way across both east and west bound dual lanes of the freeway in order to arrive at the bus shelter, while passengers that exit the bus on the eastbound lanes who wish to enter the caravan park (or the Rockbank township at that location) must also negotiate across both lanes of the freeway. This often occurs when vehicular traffic is extremely heavy at peak times and pedestrians are often reported to be

crossing the freeway dangerously amongst traffic in all weather and lighting conditions.

Coroner’s Investigator Leading Senior Constable (LSC) Craig Kelso expressed concerns regarding the freeway crossover points as most of them have no form of illumination (street lighting) and are, according to LSC Kelso, a major safety hazard to both motorists and

pedestrians.

COMMENTS

Pursuant to Section 67(3) of the Coroners Act 2008, I make the following comment connected with the death:

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Although LSC Kelso’s concerns were not strictly related to the particular circumstances of Mr Warrick’s death, the Coroners Prevention Unit? were asked to review the circumstances of Mr Warrick’s death on behalf of the Coroner. The CPU obtained the VicRoads Road Crash Information System for the relevant Freeway section and the Western Freeway Rockbank to

Melton Access Restoration Project Strategy.

? The Coroners Prevention Unit (CPU) was established in 2008 to strengthen the prevention role of the coroner, The unit assists the coroner with research in matters related to public health and safety and in relation to the formulation of prevention recommendations, as well as assisting in monitoring and evaluating the effectiveness of the recommendations. The CPU comprises a team with training in medicine, nursing, law, public health and the social sciences.

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The CPU contacted Mr Francis To, Office Manager of VicRoads Legal Services and requested VicRoads’ assistance on the feasibility of the following recommendations made by

LCS Kelso:

a. re-locating the main entry for the Sundowner Caravan Park from the Western Freeway to Westcott Parade, Rockbank which runs directly behind the caravan

park on its south side;

b. re-locating the bus-stops located either side of the freeway to Westcott Parade,

Rockbank adjacent to the park's main entrance; c. having the Route 456 Sita Bus service re-routed to reflect the above; and

d. having the freeway crossover points at Troups Road North, the Sundowner Caravan Park, the Rockbank Garden Centre (Nursery), Paynes Road and Mt Cottrell Road barricaded off and re-directing traffic to utilise the major exchanges located Robinsons Road, Christies Road, Hopkins Road, Leakes Road, Ferris Road and Coburns Road.

On 15 July 2014, Mr To advised that during the period 1 January 2009 and 31 December 2013, there have been 191 reported crashes on the Western Highway from Robinsons Road,

Ravenhall to Djerriwarrh Creek, including four fatalities.

Mr To also advised that in 2011, Aurecon conducted a high level study to identify implementing freeway standard access along the Western Freeway, between Melton Highway and the Deer Park Bypass inclusive. The study found that existing access arrangements do not

comply with the VicRoads AMP 1 requirements applicable to the Western Freeway.

As part of the upgrade, many short term and long term recommendations were made. Short term recommendations included the closure of the side roads with (private) access restoration (service) roads provided connected to the truncated side roads. In the long term, full freeway

interchanges will be provided with bus stops on the exit ramps.

All recommendations proposed by the Coroner’s Investigator, with the exception of the location of the bus stop and the re-routed 456 Sita Bus service, which falls under Public Transport Victoria’ jurisdiction, were recommendations made in the Western Freeway

Rockbank to Melton Access Restoration Project Strategy.

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VicRoads has adopted and endorsed a strategy for the Western Freeway. To date however,

this project has not received Government funding.

Melton City Council were included in stakeholder consultation during the study and have expressed interest in Mount Cottrell Road being considered as a priority project. There have been four recorded crashes near this intersection in the last five years including a double fatality® investigated by Coroner Byrne. These coronial matters involved a double motor vehicle fatality that occurred when an oncoming 4WD travelling east along the Western Freeway struck their vehicle as it pulled out from the north side of the Freeway heading

towards the south side at the Mount Cottrell Road crossover in Melton.

Coroner Byrne considered LSC Kelso’s concerns and the CPU investigation for the purpose

of his Findings dated 29 October 2014. Coroner Byrne made a recommendation as follows:

I recommend that earnest consideration be given to the closing of the median “strip

crossover” on the Western Highway at: e Troups Road North; e The Sundowner Caravan Park; e The Rockbank Garden Centre (Nursery) e Paynes Road; and e Mount Cottrell Road.

Coroner Byrne’s Findings were distributed to VicRoads, the Secretary of Transport, Planning

and Local Infrastructure and the Melton City Council. I note that in accordance with section

72(3) of the Coroners Act 2008, the response is not yet due.

RECOMMENDATIONS

Pursuant to Section 72(2) of the Coroners Act 2008, I make the following recommendation

connected with the death:

Although the circumstances surrounding Mr Warrick’s death did not involve the relevant crossovers

per se, the investigation highlighted that the Western Freeway is and remains dangerous at these

points. I accordingly adopt and repeat Coroner Byrne’s recommendations made in the matters of

COR 20136349 and COR 20135350.

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John Pace (COR 2013 5350) and Margaret Pace (COR 2013 5349) and recommend that consideration be given to closing the median “strip crossovers” at the locations specified in

paragraph 31 above.

FINDINGS

I find that the care received by Mr Warrick by the Sunshine Hospital Emergency Crisis Assessment and Treatment Team on 25 August 2013 was appropriate in the circumstances and I accordingly

make no adverse finding or comment.

I accept and adopt the medical cause of death as identified by Associate Professor David Ranson and find that Mr Shane Kenneth Warrick died from multiple injuries in circumstances where I am

satisfied that he intended to take his own life.

I acknowledge the extensive research and synthesis of data performed by the Coroners Prevention

Unit.

Pursuant to section 73(1) of the Coroners Act 2008, I order that the following be published on the internet.

I direct that a copy of this finding be provided to the following: Mr Kenneth Warrick Mr Peter Kelly, Melbourne Health Dr Mark Oakley Browne, Chief Psychiatrist Ms Karen Macdonald, VicRoads The Secretary of Transport, Planning and Local Infrastructure Melton City Council

Leading Senior Constable Craig Kelso

Signature:

AUDREX JAMIESON CORONER Date: 28 November 2014

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