Finding into death of Trendafil Petrovski

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2013 4700

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 TRENDAFIL PETROVSKI

without holding an inquest: find that the identity of the deceased was TRENDAFIL PETROVSKI born 6 May 1935 and the death occurred on 17 October 2013 at The Royal Melbourne Hospital, 300 Grattan Street, Parkville Victoria 3050 from: 1(a) HEAD INJURY SUSTAINED WHEN STRUCK BY A CAR

Pursuant to section 67(1) of the Coroners Act 2008, I make findings with respect to the following circumstances:

1. Trendafil Petrovski was 78 years of age at the time of his death. He lived at 83 Roseleigh Boulevard, Sydenham with his wife, Mileva Petrovska and was retired. Mr Petrovski’s medical

history included gastric cancer, a splenectomy and depression.

2. Onthe morning of 16 October 2013, Mr Petrovski and Mrs Petrovska planned to go for a walk to Watergardens Shopping Centre. Mrs Petrovska was still indoors when Mr Petrovski walked

outside their house, which is situated at the corner of Robina Road.

3. At approximately 8.22am, Mr Petrovski stepped onto Robina Road, in the path of a silver Holden Barina, being driven by Gaurav Rangras. Mr Rangras had been travelling east along Roseleigh Boulevard and had turned right into Robina Road, striking Mr Petrovski

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approximately two metres from the kerb. Mr Petrovski was thrown onto the windscreen, and fell onto the roadway, striking his head on the road surface. Mr Rangras stopped his vehicle in the middle of the road, rendered assistance to Mr Petrovski and waved down a passer-by, who called emergency services. Mrs Petrovska arrived at the scene, and ambulance paramedics attended at 8.30am, followed shortly afterwards by police. Mr Petrovski was conscious and breathing, but in an altered conscious state. He was conveyed to the Royal Melbourne Hospital

by a Mobile Intensive Care Ambulance, arriving at approximately 9.45am.

4. On arrival, Mr Petrovski was reviewed by the trauma team and neurosurgery were notified.

Following a computed tomography (CT) scan of Mr Petrovski’s brain, he was taken to theatre for a craniotomy, evacuation of right sided haematoma and insertion of an intracranial pressure monitor. Post-operatively, intracranial pressure increased, and a repeat CT brain scan demonstrated a progression of a subdural haematoma with a new parenchymal haematoma. A family meeting was held regarding Mr Petrovski’s poor prognosis. He was subsequently extubated at 12.30am, and declared deceased at 1.32am on 17 October 2013.

INVESTIGATIONS Forensic pathology investigation

5. Dr Sarah Parsons, Forensic Pathologist at the Victorian Institute of Forensic Medicine, performed an external examination upon the body of Mr Petrovski, reviewed a post mortem CT scan, medical deposition and medical notes from the Royal Melbourne Hospital, and referred to the Victoria Police Report of Death, Form 83. On reviewing the CT scan, inter alia, Dr Parsons noted bilateral frontal and temporal haemorrhagic contusions and skull fractures.

Toxicological analysis of ante mortem blood identified morphine,’ midazolam? and

mirtazapine’ at therapeutic levels.

6. Based on the evidence available to her, Dr Parsons ascribed Mr Petrovski’s death to a head

injury sustained when struck by a car.

' Morphine is a narcotic analgesic used to treat moderate to severe pain, ? Midazolam is a short acting benzodiazepine used intravenously in intensive care patients.

• Mirtazapine is indicated for the treatment of depression,

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Police investigation

The circumstances of Mr Petrovski’s death have been the subject of investigation by Victoria Police on my behalf. Police obtained statements from Mr Petrovski’s wife Mileva Petrovska, General Practitioner Dr Leonard Uta, two bystanders and Ambulance Paramedic Aaron Romera, as well as a non-arrest, statement interview with drier Gaurav Rangras on 31 October

Dr Uta stated that he had seen Mr Petrovski on several occasions since 19 August 2008. Dr Uta reported that Mr Petrovski had suffered from arthritis, and earlier had carcinoma of the stomach. Following surgery (a gastrectomy and splenectomy) in October 2007, he had experienced no recurrences of the condition, but had developed depression, for which he was taking the antidepressant mirtazapine. At his last consultation on 13 September 2013, Mr Petrovski had undergone an annual health assessment and was not found to have any major

health problems.

Mrs Petroyska stated that she had been married to Mr Petrovski for 31 years. She confirmed that after the last general check up with Dr Uta, Mr Petrovski had been told he had no health issues. Mrs Petrovska stated that her husband was never sick and very rarely visited the doctor.

She added that he was a happy man and that they spent most of their time together. Mrs Petrovska was not aware of her husband having any mental health issues, including depression, nor any past surgery. They walked each morning, and she described him as very healthy for his

age. Mr Petrovski did not drink alcohol or smoke cigarettes.

Mr Rangras stated that he had been looking ahead and paying attention to his driving at the time of the collision. He said that he had physically stopped his car in Roseleigh Boulevard before turning right into Robina Road. Mr Rangras said he first saw Mr Petrovski when he had turned the corner and he was standing in front of his car, just before the collision. He added that the weather had been fine, visibility was clear and that he had been wearing his glasses.

There had been no other traffic on the street at the time. Mr Rangras told police that he had not been in a rush, because he did not have to go to work until 12 noon, and he had not felt tired.

He said that he had not been taking any medication and did not suffer from any medical conditions. Mr Rangras had undertaken a preliminary breath test when police arrived at the scene, and he said that he had not drunk alcohol for approximately a month prior to the

incident.

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Following his interview, police determined that no criminal charges were applicable in relation to Mr Rangras’ involvement in the collision. Mr Rangras had a full and current Victorian Licence, held no traffic history or convictions, and was not recorded on the Law Enforcement

Assistance Program (LEAP) Data Base with any criminal history.

In the course of their investigation, police found that weather conditions were not a factor in relation to this collision. It was confirmed that visibility was clear, traffic at the time was light and the road was dry. There was slight cloud cover at the time of the collision and direct sunlight did not play a role in respect to Mr Rangras’ visibility. Road surface showed a tiled, cobblestone paved area at Robina Road, near the intersection with Roseleigh Boulevard.

Robina Road has a speed limit of 50km/h, and police did not raise the issue of speed having

contributed to the collision.

The Coroner’s Investigator, First Constable Jaclyn Larkin, provided information and images which show that Robina Road ‘bottle necks’ approximately 15m away from Roseleigh Boulevard, so that only one vehicle can pass through at one time. However, First Constable Larkin noted that there are no signs to let road users know who has to give way at that point. In this respect, First Constable Larkin opined that it may be dangerous, as the intersection is quite narrow and near the turning point. She suggested that the road design should be addressed;

whether it be by widening the road or applying signage.

Further investigation

14. On 17 June 2015, the Court received correspondence from Michael Kyriakakis, Principal Lawyer of VicRoads Legal Services, to advise that both Robina Road and Roseleigh Boulevard in Sydenham are on the Register of Public Roads of the Brimbank City Council and are not the responsibility of VicRoads.

RECOMMENDATION

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

connected with the death:

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I recommend that the Brimbank City Council undertake a feasibility assessment at the intersection of Robina Road and Roseleigh Boulevard in Sydenham, to determine whether it

requires safety enhancements in addition to the pre-existing ‘bottleneck’ structure, such as

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increased signage to warn motorists to give way to pedestrian traffic, and / or whether a

delineated pedestrian crossing would improve pedestrian safety.

FINDINGS

I accept and adopt the medical cause of death as identified by Dr Sarah Parsons and find that

Trendafil Petrovski died from a head injury sustained when he was struck by a car.

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

I direct that a copy of this finding be provided to the following:

Mrs Mileva Petrovska

Ms Kellie Gumm, Trauma Program Manager, the Royal Melbourne Hospital

Brimbank City Council

First Constable Jaclyn Larkin

Signature:

AUDREY JAMIESON 7 | | CORONER OC

Date: 17 May 2016

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