Finding into death of LX
A 31-year-old man subject to a post-sentence supervision order died from mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen) at a residential facility. He was a vulnerable person with acquired …
Deceased
JOHN PACE
Demographics
79y, male
Coroner
Coroner Phillip Byrne
Date of death
2013-11-22
Finding date
2014-10-29
Cause of death
HEAD AND CHEST INJURIES SUSTAINED IN A MOTOR VEHICLE COLLISION (DRIVER)
AI-generated summary
A 79-year-old man died in a motor vehicle collision at a median strip crossover on the Western Freeway. He had consumed alcohol (one light beer) and pulled his vehicle directly into the path of an oncoming vehicle travelling at highway speed, with the other driver having no time to brake. While the deceased's vehicle had inadequate tyre tread, this did not contribute to the collision. The coroner found the primary issue was unsafe median strip crossovers on the Western Freeway that allow side-road traffic to cross multiple carriageways. No medical or clinical factors contributed to this death. The key lesson is the importance of road safety infrastructure design in preventing such collisions.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
IN THE CORONERS COURT ‘OF VICTORIA AT MELBOURNE Court Reference: COR 2013 5350
Form 38 Rule 60(2) Section 67 of the Coroners Act 2008
{, PHILLIP BYRNE, Coroner having investigated the death of JOHN PACE ,
without holding an inquest:
find that the identity of the deceased was JOHN PACE born on 2 November 1934 ,
and the death occurred on 22 November 2013
at the intersection of Mt Cottrell Road and the Western Freeway, Melton from:
1(a) HEAD AND CHEST INJURIES SUSTAINED IN A MOTOR VEHILCE
Pursuant to section 67(2) of the Coroners Act 2008, I make findings with respect to the following
circumstances:
lL. Mr John Pace, 79 years of age at the time of his death, resided at 768 Greigs Road, Rockbank, Victoria 3335 with his wife Mrs Margaret Pace.
asthma, anxiety, hearing loss and cataracts.
John Pace, who was driving, only had one light stubby all night.
leaving the property as it lit up a rabbit on the driveway. He also said that when they
lof $
were leaving Mr John Pace said that they would cross the Western Freeway at Mt
Cottrell Road, and that the crossing should be quiet at that time of night.
Driving conditions that night were relatively good. Although it was dark at that time and the Mt Cottrell Road/Western Freeway was not lit, the weather was fine, visibility
was clear and the road surface was dry.
Mr John Burr was heading east along the Western Freeway towards Melbourne in a Lexus 4WD wagon. He was accompanied by two passengers, Mr Vincent Lee and Mr Marco Matic. As they approached the Mt Cottrell Road crossover Mr Pace’s vehicle pulled out from the north side of the Highway heading towards the south side. Mr Burt’s vehicle collided with Mr Pace’s vehicle with the impact occurring on the drivers side door of Mr Pace’s vehicle. Mr Pace’s car was pushed approximately 50m along the
freeway as a result of the collision.
Mr Butr in his statement to the court describes the red car driving out in front of his yelhticle when he was about 5 metres away from the crossover. He stated that he had no time to brake or take evasive action. He describes how the front of his car hit the drivers
door area of the red car and how it was a really hard impact.
Both vehicles came to a stop against the roadside barriers. The three occupants in the Lexus had relatively minor injuries and we able to exit their vehicle. They checked on Mr and Mrs Pace and both appeared to be deceased. Mr Vincent Lee called ambulance
paramedics who attended and formally pronounced both Mr and Mrs Pace deceased,
As the death was unexpected the matter was referred to the Coroner. Upon coronial direction an external only post mortem examination was carried out at the Victorian Institute of Forensic Medicine by Senior Forensic Pathologist Dr Noel Woodford. Dr Woodford found that cause of death was head and chest injuries sustained in a motor
vehicle collision (driver).
As part of the Victoria Police investigation into this incident Senior Constable Nick Brickley of the Mechanical Inspection Unit inspected both vehicles. He noted that Mr and Mrs Pace’s Toyota Camry would have been classed as being in an unsafe condition prior to the impact due insufficient tyre tread depth on three of the four tyres. However he noted that this fact would not have any bearing on the collision. His inspection did not reveal any mechanical fault with the vehicle that would have caused or contributed
to the collision.
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Senior Constable Brickley’s inspection of the Lexus 4WD wagon found that the vehicle
would have been classed as being in a safe mechanical condition prior to the collision.
Pursuant to section 67(3) of the Coroners Act 2008, I make the following comment(s) connected with the death:
The Coronial Investigator, Leading Senior Constable Craig Kelso of the Melton Highway patrol, provided the Court with very comprehensive Briefs of Evidence in relation to the deaths of Mr and Mrs Pace. I commend his thoroughness. Importantly, in what is titled a Briefing Note, Leading Senior Constable Kelso makes strong
recommendations concerning several median strip “crossover points” at:
e Troups Road North
e The Sundowner Caravan Park
e¢ The Rockband Garden Centre (Nursery)
e Paynes Road
¢ Mount Cottrell Road
The “crossover points” allow traffic from those side roads wishing to travel in an easterly direction (towards Melbourne) to cross the west bound carriageway of the highway towards Ballarat, or intending to travel in a westerly direction (towards
Ballarat) to cross the east bound carriageway of the highway towards Melbourne.
Leading Senior Constable Kelso urges me to recommend those crossovers be “barricaded off’; closed to traffic so that drivers wishing to travel in either direction would be required to utilise the major exchanges” located at Robinsons Road, Christies
Road, Hopkins Road, Leakes Road, Ferris Road and Coburns Road.
The same issue was referred to Coroners Prevention Unit! by my colleague Coroner
Jamieson in an unrelated matter. Investigations undertaken by that unit sought input by
' The Coroners Prevention Unit (CPU) was established in 2008 to strengthen the prevention role of the Coroner. The CPU assists the Coroner in formulating prevention recommendations and in monitoring and evaluating the effectiveness of recommendations once published.
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VicRoads as to the feasibility and appropriateness of closing off those median strip
“crossover points”.
including four fatalities. He further advised that a “high level study” was undertaken. It
would appear that the recommendations proposed by Leading Senior Contable Kelso accord with recommendations of the Western Freeway Rockbank to Melton, Access Restorations Project Strategy which were, I am advised, adopted and endorsed by
VicRoads. To date that project has not been funded.
Pursuant to section 72(2) of the Coroners Act 2008, I make the following recommendation(s) connected with the death:
Lacknowledge the helpful input by the Coroners Prevention Unit.
crossovers” on the Western highway at:
e Troups Road North
e The Sundowner Caravan Park
e The Rockband Garden Centre (Nursery) e Paynes Road
e Mount Cottrell Road
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I direct that a copy of this finding be provided to the following: Ms Joanne Pace
Leading Senior Constable Kelso, Melton Highway Patrol
VicRoads The Secretary of Transport, Planning & Local Infrastructure Melton City Council Signature: a
CORONER SN Date: 29 October 2014
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