Finding into death of Zheng Xiang Gao

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2014 006456

FINDING INTO DEATH WITHOUT INQUEST

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

I, PARESA ANTONIADIS SPANOS, Coroner,

having investigated the death of ZHENGXIANG GAO without holding an inquest:

find that the identity of the deceased was ZHENGXIANG GAO born on 22 November 1994 and that the death occurred on 21 December 2014

at Number Four Beach, Venus Bay, Victoria

from:

L(@) DROWNING

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

Mr Gao was a 20-year old student who arrived in Australia from China in 2013.to study engineering at Monash University. He lived with his friend and fellow student, Xing Sun, in

Clayton.

On 21 December 2014, Mr Gao, Mr Sun and their friends Zhihang Li, Sui Du and Lei Pei decided to go to Number Four Beach in Venus Bay to collect crabs to cook and eat. Although the friends had been to a number of Victorian beaches together for picnics, none but Mr Sun had ever been to Number Four Beach and none of them ever swum in the ocean. Indeed, none of the friends considered themselves ‘good’ swimmers and it is not clear that Mr Gao could

swim at all.

Venus Bay beach runs for about 25 kilometres between Point Smythe and Arch Rock in south Gippsland. There are five public access beaches, numbered.One through Five, spread over four kilometres of coastline known to be highly hazardous due to large waves, strong currents

and sand bars that create strong rips. Beach Number One is the bay’s primary beach and is the

only beach patrolled! by Venus Bay Surf Life Saving Club [VBSLSC] which performed over 150 rescues between November 2009 and April 20142

4. Atabout 11.00am on 21 December 2014, Mr Gao and his friends arrived at unpatrolled Number Four Beach having walked the downhill sandy path from the car park. The weather was a sunny 27 degrees Celsius, with light north easterly winds that changed to light south westerly in the afternoon, High tide was at 11.24am with low tide at 5.29pm.

5. Mssrs Gao, Sun, Li and Du began searching for crabs while Ms Pei stayed with their bags on the beach. As it was high tide, the men waded through knee-deep water to find crabs for about an hour before breaking for lunch. At about 1.30pm, Mr Du and Ms Pei left the beach in search of a bathroom while Masrs Gao, Sun and Li resumed crabbing, walking some

distance down the beach to reach the receding water, the tide having turned by this time.

6. After about ten minutes of crabbing in knee-deep water, Mr Gao and his two friends found themselves in water up to their waists. Considering the conditions to be too dangerous to continue, the group decided to return to the beach. However, before they could do so they

_-were struck from behind by a series of waves and were sucked out to sea in a rip current.

7. Mr Gao became separated from his friends by about three and five metres. He was flapping his arms and attempting to keep his head above the water, and appeared to be struggling to do

so. As another large wave passed them and Mssrs Sun and Li lost sight of Mr Gao,

8. When Mssrs Sun and Li reached the shore a short time later, they discovered that Mr Goa was not on the beach. Mr Sun collapsed on the sand? and Mr Li continued along the beach to raise the alarm. He asked a woman who was on the beach with her family, Robyn Cardamore, whether she had seen Mr Gao come out of the water. She had not, but kept a look out and about ten minutes later spotted a coloured object bobbing in the waves in the area of the rip.

The colours were consistent with clothing worn by Mr Gao. Subsequent observations confirmed that what could be seen in the water was a clothed person, presumed to be Mr Gao.

While a call was made to the emergency services, Ms Cardamore tracked Mr Gao’s position in the water.

9, The 000 call led to the dispatch of VBSLSC and Community Emergency Response Team

members, Ambulance Victoria paramedics (including air ambulance) and Victoria Police.

VBSLSC life savers arrived in under 10 minutes, one by land, and two aboard an inflatable

1 Number One beach is patrolled between November and April on Saturday afternoons, Sundays and public holidays and daily between mid-December and mid-January,

2 Coronial Brief of Evidence, Appendix 8 (statistics provided by VBSLSC).

4 fe was treated at the scene and recovered.

rescue boat that was guided to Mr Gao’s position by Ms Cardamore. Mr Gao, unconscious and unresponsive, was hauled into the boat about 30 metres from shore and taken to the beach

where cardio-pulmonary resuscitation was commenced and continued for nearly 50 minutes.

Mr Gao could not be revived.

One of the responding police members, Leading Senior Constable Shaun Stirton of Inverloch Police commenced a coronial investigation of Mr Gao’s death and compiled the brief of

evidence on which this finding is largely based.

Forensic pathologist, Dr Linda Tles of the Victorian Institute of Forensic Medicine, reviewed the circumstances of the death as reported by police to the coroner, post-mortem computer assisted tomography scanning of the whole body [PMCT], and performed an autopsy. Among Dr Les’ anatomical findings were bilateral pleural effusions, pulmonary oedema and lung hyperinflation, a small amount of fluid in the stomach and an incidental finding of dysplasia

of the left anterior coronary artery.

Routine toxicological analysis of post-mortem blood samples detected no alcohol or other

commonly encountered drugs or poisons.

Although noting that the findings of drowning in the autopsy setting can be non-specific, Dr - Tes considered it reasonable to attribute Mr Gao’s death to drowning in light of her findings

and the reported circumstances of his death.

LSC Stirton’s brief of evidence includes witness statements, aerial and scene photographs, information about tide and weather conditions on the date of Mr Gao’s death and materials relating to beach safety, hazards (particularly rips), and VBSLSC’s preventative and rescue

operations between 2009 and 2014.

In his statement, LSC Stirton observed that in the 18 years he had been stationed at Inverloch he had attended Venus Bay beaches in relation to non-fatal and fatal rescue/recovery operations on several occasions. He noted the popularity of the beaches among bathers and, increasingly, among predominantly foreign-born, poor- or non-swimmers who visited to collect crabs or pipis at low tide. LSC Stirton expressed particular concern for the safety of the latter group given their likely unfamiliarity with potentially hazardous surf conditions at

Venus Bay and that individuals would be swept out to sea with greater frequency in future.

4 Among these were drownings in January 1981 and December 2002 and a near-drowning of an international (Chinese) student in December 2012, though this incident involved use of an inflatable boat. I note that a year after Mr Gao’s death, on New Year’s Eve 2015, another drowning occurred at Venus Bay, this time at Number Five Beach [COR 15/6597 — an on-going investigation at the time of writing].

16. During the investigation, LSC Stirton examined the warning signage erected at the Number Four Beach parking area. Thé warning sign incorporated information about hazards, safety and enforceable regulations. The ‘general warnings’ highlighted the beach’s strong currents, high surf and a deep trough in both words and diagrams. Below these warnings was a diagram and text indicating that the beach was iot patrolled and advising that the nearest patrolled beach was three kilometres away. Above the general warnings, was a direction to call ‘000’ in case of emergency and ‘state this number above’. However, no number appeared in the yellow triangle above that text (though the sign was labelled ‘Venus Bay Beach No.4’).

At the foot of the sign were text and diagrams indicating that camping, fires, and (unjleashed

dogs were prohibited (at particular times).

17, Inote that Mr Li told police that he recalled seeing the warning sign because it was ‘right there’ on the path from the car park to the beach, and that it referred to strong waves though he had not considered the warning particularly relevant to activities like crabbing along the shoreline. Mr Sun stated that he recalled a sign in the car park prohibiting alcohol but didn’t remember any other warnings; he said there was no sign ‘on the beach’ directing visitors ‘yshere to swim’ and that he had not appreciated the dangerousness of the beach. Mr Du

stated that he did not recall seeing ‘any signs’.

18. LSC Stirton considered that a stronger and clearer message about the dangers of entering the water could help prevent incidents similar to that in which Mr Gao died from occurring in the future. He included in the brief examples of warning signs used at American beaches where

there were rip currents or a heightened risk of drowning.”

19. Atmy request, the body responsible for maintaining beach safety signage at Venus Bay, Parks Victoria, responded to the LSC Stirton’s concerns. Gerard Delaney, Parks Victoria’s Area Chief Ranger South Gippsland and Bass, advised that all current signage at Venus Bay beaches met existing guidelines.® He acknowledged that it would be ‘appropriate’ to reinforce the ‘surf safety message’ and was ‘supportive’ of the suggestions made by the coronial

investigator.”

20, Mr Delaney advised that Parks Victoria was collaborating with the VBSLSC and Life Saving

Victoria to renew signage at the Venus Bay beaches. The project will:

51 note that several American signs, in addition to warning of dangerous rip currents (with words and pictures), contained information about how to attract attention or “break the grip ofa rip’ if caught in one, while others included messages (in English only) like ‘strong current: you could be swept away from shore and could drown’, ‘if in doubt, don’t go out’ and ‘know how to swim’.

6 That is, Australian Standard AS2416 — Design and Application of Water Safety Signs.

7 See generally correspondence from Gerard Delaney to the Court dated 21 March 2016.

a. develop new signs for all main entrances to the beaches, ensuring that any changes to the national guidelines are included;

b. incorporate ESTA’ Emergency Markers into all beach entrance signage to facilitate identification of the location of a reported incident to aid efficient dispatch of emergency services;

c. consider additional signage on approach to the beaches, such as in car parks, to reinforce the dangerous surf conditions message,

d. be assessed by signage experts at Life Saving Victoria; and

e. continue to promote swimming at the patrolled Number One Beach and identify

opportunities to improve this message.

The project is a Parks Victoria priority and signage is anticipated to be installed prior to spring 2016.

1 find that Mr Gao, late of 15 Leaf Court, Clayton, died on 21 December 2014 of drowning at the Number Four Beach at Venus Bay. On the basis of the evidence before me, it is likely that Mr Gao’s poor swimming ability contributed to his death, as did the failure of Mr Gao and his friends to appreciate that the dangers of the unpatrolled hazardous coastal location extended to

those activities in which they intended to engage, despite the presence of some warning signs.

COMMENTS

Pursuant to section 67(3) of the Coroners Act 2007, I make the following comments connected

with the death:

1. Mr Gao’s death highlights the particular vulnerability of foreign-born individuals to accidental drowning in Victorian (and Australian) coastal waters. Indeed, Life Saving Victoria estimates that 23% of individuals who drowned in Victoria in the 2014-2015 financial year were reported as being from culturally and linguistically diverse backgrounds,

a 55% increase on the 10-year average (2004-2014).?

8 ESTA is the Emergency Services Telecommunications Authority which coordinates Triple Zero call-taking and dispatch of emergency services,

9 Life Saving Victoria Drowning Report 2014/15 available at http://lsv.com.au/research/victorian-drowning-reports.

Individuals from a culturally and linguistically diverse [CALD] background are defined in the report as those who identify as having a specific cultural or linguistic affiliation by virtue of their place of birth, ancestry, ethnic origin, religion, preferred language, language(s) spoken at home or because of their parents’ identification on a similar basis. I note that the above-mentioned statistics are higher than the most recent national figures (Royal Life Saving, National Drowning Report 2015) which reports that ~5% of drownings inivolve individuals from CALD backgrounds. I note too that neither report consistently reports the frequency of drownings by (CALD) background and location of drowning

2. Although factors such as the hazardousness of the natural environment, presence of strong or rip currents, swimming ability and the availability of life savers are applicable to the safety of all visitors to beaches (especially those intending to enter the water), individuals less familiar with “beach culture” appear to be disadvantaged by their limited ability to

recognise and respond to the risks posed by beaches and waterways.

3, Beach safety signage is an important tool for providing information about risks and hazards on coastal beaches and waterways. While commending the work undertaken by Parks Victoria and its partners to renew signage and improve public awareness and safety at Venus Bay beaches, I note that the warning signs in place at the entrance to Number Four Beach on the day of Mr Gao’s death were apparently insufficient to alert him and his friends to potential dangers, despite being compliant with the relevant Australian Standard for water safety signs. Clearer signage is desirable and, given the available examples from other

jurisdictions, it is achievable.

4. Signage, though valuable, is unlikely in isolation to wholly manage the risks presented by coastal waters, particularly among beach-goers for whom warnings like ‘watch out for the rip’ and ‘swim between the flags’ - and swireming proficiency —are not as readily comprehensible or culturally ingrained as they are for many immersed in “Australian beach culture” from a young age. Water safety education is, therefore, another important tool through which to minimise unintentional drowning in coastal waters for this cohort.

Multicultural educational programs have been offered by organisations like Life Saving

Victoria for a number of years,!°

5. With this in mind, I endorse the comments made by Coroner Jamieson following her investigation of the death of Bombally [COR 2008 1153], namely, that all education and training institutions that have international students enrolled annually seek the services of Life Saving Victoria to deliver water safety information to their students. Building water safety awareness amongst this group may promote the adoption of protective behaviours and

a mote accurate assessment of risks posed by different aquatic environments.

10 See for example, Life Saving Victoria at http://sy.com.au/multicultural/educational-programs.

I direct that a copy of this finding be provided to the following: The family of Mr Gao Leading Senior Constable Shaun Stirton c/o O.1.C. Inverloch Police Parks Victoria Life Saving Victoria Council of International Students Australia

Australian Federation of International Students

Signature:

“Ppa

PARESA ANTONIADIS SPANOS CORONER.

Date: 30 September 2016

Cc: Manager, Coroners Prevention Unit