Finding into death of Trevor John O'Brien

IN THE CORONERS COURT Court Reference: COR 2018 1914

OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008 Findings of: AUDREY JAMIESON, CORONER Deceased: TREVOR JOHN O’BRIEN Date of birth: 9 June 1954 Date of death: 25 April 2018 Cause of death: Chest Injuries Place of death: 17 Carrington Crescent, Carrum Downs, Victoria 3201 Catchwords: DIY vehicle maintenance, Australian Consumer Law, Safety Standards

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

Trevor John O’Brien was 63 years of age at the time of his death. He had resided in Carrum Downs with his wife Lynette O’Brien for the past 30 years. They had two adult children Michael O’Brien and Kaitlyn O’Brien, both of whom lived out of home.

Mr O’Brien’s medical history included chronic back pain from a long-standing injury which he had sustained at work. He also had a history of depression and was prescribed anti-depressants soon after sustaining the. workplace injury. He had no history of

suicidality.

On 25 April 2018 at approximately 12.00pm, Mr O’Brien informed his wife that he intended to install a tap on the exterior of their caravan. At approximately 3.00pm, Mrs O’Brien came outside to get her husband. She called out to him and received no response. Subsequently, Mrs O’Brien approached the caravan and saw that her husband

was pinned beneath the A-Frame. He was completely unresponsive.

Mrs O’Brien immediately attempted to windup the caravan’s jockey-wheel, to no avail.

She contacted emergency services and Ambulance Victoria paramedics attended,

confirming that Mr O’Brien was deceased.

INVESTIGATIONS

Forensic pathology investigation

Dr Paul Bedford, Forensic Pathologist at the Victorian Institute of Forensic Medicine (VIFM), performed an external examination upon the body of Trevor John O’Brien, reviewed a post mortem computed tomography (CT) scan and referred to the Victoria

Police Report of Death, Form 83.

Toxicological analysis of post mortem blood identified amitriptyline (~0.02 mg/L)’ and its metabolite nortriptyline (~0.02 mg/L),” as well as Atenolol (~0.6 mg/L).’ Dr Bedford

! Amitriptyline is a tricyclic antidepressant that inhibits the reuptake of noradrenaline and serotonin, potentiating their neurotransmitter action. Amitriptyline is primarily used to treat depression but may be used to treat other mental health conditions and neuropathic pain.

2 Nortriptyline is a metabolite of Amitriptyline. A metabolite is a a substance formed in or necessary for metabolism.

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commented that there was evidence of compression of the chest resulting in significant chest injuries and mechanical asphyxia. There was no evidence of significant, naturally occurring disease which caused or contributed to the death. Dr Bedford ascribed the

medical cause of Mr O’Brien’s death to chest injuries.

Police investigation

Upon attending the Carrum Downs premises after Mr O’Brien’s death, Victoria Police officers photographed the caravan in situ. Police officers noted that the caravan jockeywheel appeared to be the sole apparatus elevating and holding the weight of the caravan

while Mr O’Brien had worked beneath it.

Senior Constable (SC) Lauren Downer was the nominated Coroner’s investigator.‘ At my direction, SC Downer investigated the circumstances surrounding Mr O’Brien’s death, including the preparation of the coronial brief. The coronial brief contained, inter alia, statements made by Mrs O’Brien, Michael O’Brien and General Practitioner (GP) Dr Zhong-Mei Liu of Skye Medical Centre.

During the investigation, police learned that Mr O’Brien had been a patient of GP Dr Liu at the Sky Medical Centre since 30 November 2015. Dr Liu stated that Mr O’Brien had sustained his back injury prior to being his patient. However, he required ongoing pain relief and support. Mr O’Brien did not seek nor receive treatment for depression from Dr Liu. Dr Liu stated that Mrs O’Brien was extremely supportive of her husband and always accompanied him to his appointments. Mrs O’Brien believed that her husband had not used anti-depressant medication for approximately 10 years prior to his death.

My Investigator made enquiries with the Frankston Hospital Mental Health team, but the

service had no record of treatment for Mr O’Brien.

Mr O’Brien consulted Dr Liu for the final time approximately two weeks prior to his

death. Dr Liu stated that the consultation was to arrange his ‘medication list for travel’°

3 Atenolol is indicated for the treatment of hypertension, angina and prevention of cardiac dysrhythmia in myocardial infarction.

4 & Coroner’s Investigator is a police officer nominated by the Chief Commissioner of Police or any other person nominated by the Coroner to assist the coroner with his/her investigation into a reportable death. The Coroner’s Investigator receives directions from a Coroner and carries out the role subject to those directions.

5 Coronial Brief, Signed Statement of Dr Zhong-Mei Liu dated 12 August 2018, p 15.

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Mr O’Brien’s family stated that he had obtained employment a short-while before his death. Michael stated that his father was extremely happy to have found work despite his back injury. He said that Mr O’Brien ‘had a whole new lease on li ’.© This sentiment was echoed by Mrs O’Brien who stated that her husband had re-gained his self-worth and that he was happy again. She commented that they had recently been on their first

ever overseas holiday together and that they had a fantastic time.

In November 2017, Mr O’Brien and his wife bought their Windsor Caravan, registration Q20207. Mrs O’Brien stated that they bought it second-hand from a private dealer in Sunbury. They had only used it once during Christmas 2017. Mrs O’Brien did not indicate that there were any issues with the caravan at that time. She said it remained in

the carport for months after they returned from holiday.

Michael stated that his father had only done a few small jobs on the caravan thus: far: painting the gas bottles different colours, putting a level on the A-Frame and preparing to paint the exterior. Michael said that Mr O’Brien was meticulous and safety conscious, he would never ‘gotten under the caravan without it being safe’.’ Michael said that his

father owned car jack stands and would use them if necessary.

On 25 April 2018, Mrs O’Brien heard her husband come in and out of the home several times while he worked on the caravan in their carport. She said that she heard the front door opening and closing. At approximately 3.00pm, Mrs O’Brien heard a “bang” while she was inside the house. Shortly thereafter, she came outside to find her husband and

discovered him unconscious underneath the caravan.

My Investigator SC Downer informed me that it appeared the jockey-wheel had slipped causing the A-Frame of the caravan to lower onto Mr O’Brien’s chest. Michael postulated that a thread in the jockey-wheel clamp may have popped, causing it to slip down. SC Downer took photographs of the incident, including photographs of the AFrame, jockey-wheel and clamp in situ. The photographs depict the j ockey-wheel to be at the closest possible position to the A-Frame. The clamp appears to be sitting very low on the pole of the jockey-wheel. There is nothing to evince that the welding of the clamp

to the A-Frame has become loosened or unstuck.

6 Coronial Brief, Signed Statement of Michael O’Brien dated 18 July 2018, p 12.

TTbid 13.

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COMMENTS

Pursuant to section 67(3) of the Coroners Act 2008 (Vic), I make the following comments

connected with the death:

Mrs O’Brien believed her husband no longer used anti-depressant medication or other medication to treat mental ill-health. Dr Liu had never prescribed him such medication.

However, the cause of Mr O’Brien’s death were injuries associated with an unnatural event and there is no evidence of a relationship between his use of antidepressant medication and his death. Accordingly, the origin of anti-depressant medication in Mr O’Brien’s post mortem toxicology is not relevant to the circumstances of his death

and J have not sought further information on this matter.

Upon review of the available photographic evidence, it appears the jockey-wheel clamp attached to the caravan A-Frame may have slipped down the pole; perhaps, as Michael O’Brien has suggested, because a thread inside the clamp has given-way. Equally, the clamp may have been positioned low on the pole at first instance and something in the internal mechanism of the jockey wheel has caused it to slip down. However, these possibilities are mere conjecture; it is not possible to conclude how the caravan came to

fall onto Mr O’Brien.

I accept Michael O’Brien’s assertion that his father was a safe and meticulous person who would not have put himself beneath the caravan had he thought it unsafe.

However, safety conscious people are still prone to the inherent dangers of Do-ItYourself (DIY) work in a skilled field. Especially if they do not realise that they are

employing unsafe practices.

Mr O’Brien used the jockey-wheel improperly, as a “jack”, to hold the weight of the caravan while Mr O’Brien worked beneath it. The intended use of the jockey-wheel is to raise and lower a load so that it may be attached to a vehicle or so supports may be placed beneath the load.® Jockey-wheels and jacks should never be used to raise a load

or vehicle so a person may work beneath them.?

8 Australian Competition & Consumer Commission, Safety Alert: Working Under A Vehicle dated 28.08.11, https://www.accc.gov.au/publications/working-under-a-vehicle-safety-alert date accessed 24.09.19.

° Ibid.

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In 2011, the Australian Competition & Consumer Commission (ACCC) published a Safety Alert: Working Under a Vehicle (“the Safety Alert”).'° The alert contained

information about the dangers posed by working under a vehicle:

Never get under a vehicle that is supported by a jack. Before lifting the vehicle, chock the wheels that will remain on the ground and don’t get under the vehicle

until it is supported by support stands."!

The Safety Alert was released in response to research conducted by the ACCC in conjunction with the National Coronial Information System (NCIS). At that time, the ACCC indicated that 46 Australians had been crushed and killed by a vehicle they were working under over the past decade.!? The ACCC indicated that most deaths were of men working under a vehicle which was lifted or supported in the incorrect manner.

Between 2000 and 2011, an average of 160 injuries each year were associated with

using vehicle jacks incorrectly.

On 19 October 2018, the ACCC published the vehicle jacks Supplier Guide.'? The guide was designed to summarise the legal requirements for the supply of that product.

The Supplier Guide states that suppliers of vehicle jacks must consult Consumer Protection Notice No. 1 of 2010.'* The Supplier Guide delineates, inter alia, mandatory safety markings for vehicle jacks or warning notices which indicate that

individuals must not work underneath vehicles which are raised by a car jack:

a. “Specific Vehicle Jacks” must be permanently and legibly marked with a warning not to get underneath a vehicle supported by a jack, the advice may be in pictogram form;

b. “Jacks Other Than Specific Vehicle Jacks” (other than “High Lift Jacks”) must be permanently and legibly marked with a notice warning against getting under a

vehicle that is supported by a jack;

10 Tbid.

" Tid.

Above n 9.

13 Australian Competition & Consumer Commission, Product Safety: Vehicle Jacks: Supplier Guide published 19 October 2018, https://www.accc.gov.au/publications/vehicle-jacks-supplier-guide date accessed 24.09.19.

\4 Trade Practices Act 1974 (Cth) — Consumer Protection Notice No. 1 of 2010 — Consumer Product Safety Standard: Vehicle Jacks.

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c. “High Lift Jacks” must include a warning notice against getting underneath a

raised vehicle, and

d. Other requirements may apply which depend on the type of vehicle jack being supplied, including instructions for the safe use which specify that no person

should place any part of their body under a vehicle supported by a jack.

On 21 June 2019, an ACCC media release indicated that 120 Australians had died following DIY car maintenance accidents between 2000 and 2019. The media release stated that most accidents and deaths occurred when someone was working beneath their vehicle which had been lifted or supported in an incorrect manner. The majority of fatalities were men aged between 40 and 49 years. In response to the updated research, the ACCC produced a video explaining the correct procedure for common DIY car maintenance tasks.!5 The Commission also published a video interview with widow

Robinette Emonson, whose husband died in similar circumstances to Mr O’Brien.'®

The statistics shared by the ACCC media release and safety alerts represent a concerning trend associated with DIY vehicle maintenance. Despite the efforts of the ACCC to increase awareness of safety issues and safety standards for vehicle jacks, the

number of fatalities continued to rise.

Mr O’Brien misappropriated a wheel-jockey and used it as a jack to improperly complete DIY work underneath his caravan. Currently, there is no specific Consumer Protection Notice for jockey-wheels under the Australian Consumer Law (ACL). Mandatory warnings against using jockey-wheels to work underneath a vehicle may prevent or lessen fatalities and injuries of Australians doing DIY vehicle

maintenance. A pertinent recommendation will follow.

'5 Australian Competition & Consumer Commission, Product Safety: DIY car repair safety published 20.06.19, https://www.youtube.com/watch?v=Ce-_6_BY_Hs date accessed 24.09.19.

'6 Ibid, Widow urges caution with DIY car repairs published 20.06.19, <https://www.youtube.com/watch? v=HOdA YOD619Q> date accessed 24.09.19.

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RECOMMENDATIONS

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

recommendations:

1. With the aim of improving public health and safety and preventing like deaths, Irecommend that the Commonwealth Minister responsible for administering the Australian Consumer Law make a Safety Standard in relation to jockey-wheels, pursuant to the Competition and Consumer Act 2010 (Cth) Schedule 2 Chapter 3 Part 3-

3 Division 1 Section 104.

2. With the aim of improving public health and safety and preventing like deaths, I recommend that the Commonwealth Minister responsible for administering the Australian Consumer Law ensure that the Safety Standard requires the suppliers of jockey-wheels to indicate that a jockey-wheel should not be used as a vehicle jack and

that it should never be used to allow an individual to work beneath a vehicle.

3. With the aim of improving public health and safety and preventing like deaths, I recommend that the Commonwealth Minister responsible for administering the Australian Consumer Law ensure that the Safety Standard requires suppliers of jockeywheels to employ the use of warning notices, instructions and/or permanent, legible

product labels to indicate the warnings noted in Recommendation 2.

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FINDINGS

The investigation has identified that Mr O’Brien received fatal injuries while doing maintenance work underneath his caravan. Mr O’Brien improperly used the caravan jockey-

wheel as a vehicle jack and proceeded to do work underneath the vehicle.

T accept and adopt the cause of death ascribed by Dr Paul Bedford and I find that Trevor John O’Brien died from chest injuries, in circumstances where I find that his death was the unintended consequences of his reliance on a jockey wheel to support the weight of his

caravan,

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

published on the internet.

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

Mrs O’Brien The Hon Michael Sukkar MP, Minister for Housing and Assistant Treasurer!” Ms Delia Rickard, Deputy Chair, Australian Competition & Consumer Commission

Senior Constable Lauren Downer

Signature:

Zz Arsauy JAMIESON

CORONER

Date: 4 October 2019

'7 The Commonwealth Minister responsible for administering the Australian Consumer Law, as at 4 October 2019.

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