Finding into death of Christina Maree Chamberlain

IN THE CORONERS COURT Court Reference: COR 2018 3423

OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Amended pursuant to section 76 of the Coroners Act 2008 on 22 May 2020 Findings of: AUDREY JAMIESON, CORONER Deceased: CHRISTINA MAREE CHAMBERLAIN Date of birth: 6 July 1958 Date of death: 16 July 2018 Cause of death: Multiple injuries sustained in a motor vehicle incident (driver) Place of death: Great Alpine Road, Eurobin Victoria 3739, at exactly the 59-kilometre post 1 of 9

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

1. Christina Maree Chamberlain was 60-years-old at the time of her death

2. On 16 July 2018, Ms Chamberlain was the sole occupant and driver of a 2011 Volkswagen Crafter mobile home (vehicle) travelling west on the Great Alpine Road, Eurobin. She was being followed by her daughter, who observed Ms Chamberlain’s vehicle drift from the left lane, across the road and into the right lane before colliding with a tree.

3. The collision forced the steering column and steering wheel to the roof of the vehicle.

Ms Chamberlain was located in the driver seat, visibly injured from the waist down. She was declared deceased at the scene upon the arrival of emergency services.

INVESTIGATIONS Forensic pathology investigation

4. Dr Gregory Young, Forensic Pathologist at the Victorian Institute of Forensic Medicine (VIFM), performed an autopsy upon the body of Ms Chamberlain, reviewed a post mortem computed tomography (CT) scan, medical notes from Beechworth Surgery, medical notes from St Vincent’s Hospital and referred to the Victoria Police Report of Death, Form 83.

5. Dr Young commented that the autopsy showed significant injuries to Ms Chamberlain’s torso (right haemothorax, rib and sternal fractures, haemoperitoneum, liver lacerations) and back (fractured T6 thoracic vertebra and extradural haemorrhage around the spinal cord). Fractures through both lower legs were also noted.

6. Dr Young further commented that based on his findings, there was no way to determine whether the Ms Chamberlain had fallen asleep at the wheel. He noted that cardiomegaly is enlargement of the heart. The predicted normal heart weight in a woman of Ms Chamberlain’s weight is 329 grams, with a 95th percentile of 482 grams. The predicted heart weight of a woman measuring Ms Chamberlain’s height is approximately 239 grams, with a 95th percentile of 368 grams. Ms Chamberlain’s heart weight was 629 grams.

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7. Increased heart mass is correlated with increased cardiac mortality and morbidity. It is also an independent risk factor for sudden death due to cardiac arrhythmia (“heart attack”). Cardiomegaly is commonly associated with hypertension, of which Ms Chamberlain suffered. Dr Young further detailed that while people with hypertensive heart disease are at increased risk of a cardiac arrythmia, there was no autopsy evidence of any ischaemic change or significant coronary artery atherosclerosis in Ms Chamberlain’s heart to indicate that this may have contributed to the incident.

8. Toxicological analysis of Ms Chamberlain’s blood showed the presence of oxycodone1, amitriptyline and its metabolite nortriptyline2, sertraline3, diazepam and its metabolite nordiazepam4, promethazine5, carbamazepine and its metabolite carbamazepine 10,11epoxide6, metoprolol7, ondansetron8 and paracetamol9. Dr Young noted that many of the abovementioned medications are capable of causing drowsiness although, he was unable to say with certainty that this was the case with Ms Chamberlain.

9. Medical notes obtained during the investigation detail that Ms Chamberlain had a medical history that included type 2 diabetes mellitus, coronary artery spasm, coronary artery stints, hypertension, hypercholesterolaemia, congestive cardiac failure, left plantar fascia release, back pain, bilateral meralgia paraesthetica, sciatica, diverticulitis, right rotator cuff syndrome, osteoarthrosis, migraine, depression, gastro-oesophageal reflux disease, fibromyalgia, compartment syndrome, keratosis, right membrane perforation, gastritis, endometriosis and pelvic adhesions, bladder prolapse and hypokalaemia.

10. Dr Young ascribed the cause of death to multiple injuries sustained in a motor vehicle incident (driver).

1 Oxycodone is used clinically to treat moderate to severe pain (corrected to “moderate to severe pain” from “depression” pursuant to section 76 of the Coroners Act 2008).

2 Amitriptyline is an antidepressant.

3 Sertraline is an antidepressant for use in cases of major depression.

4 Diazepam is a sedative/ hypnotic drug.

5 Promethazine is an ani-histamine.

6 Carbamazepine is an antiepileptic drug indicated for the treatment of partial and tonic-clonic seizures, neuropathic pain and bipolar disorder.

7 Metoprolol is an anti-hypertensive drug.

8 Ondansetron is clinically used to treat nausea and vomiting in post-operative patients and in those receiving cytotoxic chemotherapy and radiotherapy.

9 Paracetamol is an analgesic drug.

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Police investigation

11. Upon attending the scene of the incident after Ms Chamberlain’s death, Victoria Police found Ms Chamberlain’s vehicle impacted into the tree, with Ms Chamberlain still in the driver seat. The vehicle speedometer was locked at 71 kilometres an hour and the engine speed was 2000 revolutions per minute.

12. Leading Senior Constable (LSC) Rohan Clapham was the nominated Coroner’s Investigator.10 At my direction, LSC Clapham investigated the circumstances surrounding Ms Chamberlain’s death, including the preparation of the coronial brief.

The coronial brief contained, inter alia, statements made by her daughter, witnesses and investigating officers.

13. During the investigation, police learned that Ms Chamberlain was a widowed mother and grandmother who lived in Wooragee at the time of her death. On 13 July 2018, she travelled from Wooragee to Bright in a vehicle that she had purchased two months prior.

At Ms Chamberlain’s request, her daughter, Amanda Reeve, was travelling behind her in a separate vehicle to ensure her mother was correctly positioned within the lane. The purpose of the journey was for a short family holiday.

14. Ms Reeve’s stated that from her point of view behind her mother’s vehicle, she could not identify any issues with her mother’s driving. Ms Chamberlain had told Ms Reeves that she felt comfortable driving the vehicle because the higher driving position was better for her.

15. Over the weekend holiday, Ms Chamberlain told Ms Reeves that she was not sleeping well. Ms Reeves stated that her mother suffered insomnia and back pain, for which she was being treated with various medications. A statement from Ms Chamberlain’s treating clinician, Dr Kylie Alexander, details a diagnosis of chronic back pain/ degenerative disc disorder and sleep apnoea. Ms Chamberlain also suffered a prolapsed disc and had a spinal fusion in 2004. Dr Alexander further detailed a conversation she had with Ms Chamberlain regarding the use of Endone and driving. Ms Chamberlain told Dr Alexander that she would never take it prior to driving.

10 A 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.

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16. On the afternoon of 15 July 2018, Ms Chamberlain had a long sleep. Ms Reeves states that after this, her mother appeared fine.

17. On 16 July 2018, Ms Chamberlain and Ms Reeves left Bright to return to Wooragee at approximately 11.00am. Prior to departing, Ms Reeves told her mother that if she felt too tired to drive, then her husband could be driven out to drive the vehicle back. Ms Chamberlain declined the offer, stating that she was okay to drive.

18. Upon departure, Ms Reeves drove behind Ms Chamberlain. Ms Reeves stated that the two vehicles maintained a speed of approximately 80 kilometres an hour.

19. At approximately 11.20am, the convoy were driving west along the Great Alpine Road, Eurobin, towards Myrtleford. The weather was fine, visibility was good, the road was dry and the traffic was moderate. Ms Reeve’s was still travelling behind Ms Chamberlain. Ms Reeve’s stated that her mother’s positioning on the road was fine.

20. As the convoy approached the 59 kilometre post at approximately 11.25am, Ms Reeve’s noticed that her mother’s vehicle was drifting out of the lane towards the right. Ms Reeve’s detailed that when the vehicle’s driver side wheels crossed the centre line, she ‘knew there was something wrong’ and started sounding her car’s horn in an attempt to get her mother’s attention.

21. Ms Reeve’s efforts to get her mother’s attention did not meet with success and Ms Chamberlain’s vehicle continued to veer to the right into the opposing lane. Ms Chamberlain’s vehicle left the road and collided with a large tree. At no time did Ms Reeve’s see brake lights on the vehicle before impact.

22. Kevin Hall was driving in the opposite direction and saw Ms Chamberlain’s vehicle veer onto his side of the road before colliding with the tree. Upon seeing the incident, he stopped and rendered assistance. He states that at no point did he see the vehicle brake or suddenly steer prior to impact. Mr Hall also stated that when he approached Ms Chamberlain, she was attempting to move her arm. As Mr Hall checked Ms Chamberlain for a pulse, Ms Reeve’s got out of her vehicle and ran to her mother. Ms Reeve’s stated that when she approached the driver’s side, she could see her mother was partially conscious.

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23. Ms Reeve called emergency services and handed the phone to Mr Hall. Ms Chamberlain was unconscious and Mr Hall could not find a pulse. Shortly after the Country Fire Authority, Victoria Police and Ambulance Victoria arrived.

24. Paramedics were unable to revive Ms Chamberlain and she was declared deceased at the scene.

25. Victoria Police investigations detail that the area of the incident is a straight and flat stretch of bitumen surfaced road in a rural area on the Great Alpine Road, Eurobin.

There is a painted dividing line and painted roadside boundary lines on either side of the road. The total width of the road is approximately 8.6 metres. The terrain on either side is flat grass.

26. The road was noted to be dry with no evidence of oils and, or lubricants on the surface.

There were no markings on the road suggestive of heavy breaking. At this location, there is no crash barrier installed. Police further noted that there were no skid marks on the gravel and grass area between the road and the tree.

27. The speed limit is set at 100 kilometres an hour. Police also noted that the weather was fine and visibility was good upon their arrival.

28. The tree was measured as being approximately 1.3 metres in diameter and 5.3 metres from the edge of the paved road. The distance from where the vehicle had initially departed the road and impacted the tree was approximately 26 metres. The tree had intruded approximately 1.3 metres into the vehicle.

29. Police noted that Ms Chamberlain was wearing her seatbelt.

30. Victoria Police Major Collision Investigation Unit (MCIU) compiled a reconstruction report on the incident. The reconstruction estimated Ms Chamberlain’s speed to be between 68 kilometres an hour and 78 kilometres an hour at the time of impact. There was no evidence that excessive speed was a factor. It was further noted that her mobile phone was located in her pocket and was unlikely to have been the cause of distraction.

31. The reconstruction report further noted that there was no evidence that the vehicle was out of control before colliding with the tree. ‘A lack of evasive action in the form of either braking or steering could be consistent with a driver who is asleep, unconscious, 6 of 9

distracted, suffering a medical episode or driving into the object deliberately. Typically, a distracted driver will react by either braking or steering between leaving the road and colliding with the tree. A driver deliberately driving into a tree to end their life will not usually slow and would generally be travelling faster than 69 km/h.’ The speed loss from driving at 80 kilometres an hour, as detailed by Ms Reeve, down to approximately 69 kilometres an hour at impact is considered consistent with the vehicle ‘rolling’ for between 64 and 96 metres between 3.1 and 4.5 seconds before impact. This was further considered consistent with Ms Chamberlain being asleep, unconscious or suffering a medical episode.

32. The Victoria Police Mechanical Investigations Unit (MIU) inspected the vehicle and compiled an inspection report on the condition of the vehicle. The report details that the vehicle was in good condition. There was no evidence to suggest a mechanical failure caused or contributed to Ms Chamberlain’s death.

33. Despite being relatively inexperienced at driving the vehicle, it does not appear Ms Chamberlain’s driving caused or contributed to her death. The vehicle was appropriately registered and Ms Chamberlain held a valid driver licence.

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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:

34. Further investigations revealed that within the last three years, Victoria Police have attended two additional incidents of similar circumstances, along the same stretch of road. In both these cases, the vehicle left the road and struck a tree located along the roadside, causing injuries to occupants.

35. I consider this number to be of concern and potentially evidence of a need to install safety barriers along the roadway to prevent vehicles from leaving the road.

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

1. With the aim of promoting public health and safety and preventing like deaths, I recommend that the Department of Transport review the circumstances of this collision, in particular the location, as identified by Leading Senior Constable Rohan Clapham of Victoria Police, with the view to install safety barriers along the road.

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FINDINGS

1. I find that Christina Maree Chamberlain, born 6 July 1958, died on 16 July 2018 on the Great Alpine Road, Eurobin Victoria 3739 at exactly the 59-kilometre post.

2. I find that there is no evidence to suggest Ms Chamberlain intended to take her own life. There is evidence of significant natural disease processes and evidence of the presence of medication that may cause drowsiness but I am unable to make any definitive findings on whether they have contributed to the cause of the collision.

3. I accept and adopt the cause of death ascribed by Dr Gregory Young and I find that the cause of Christina Maree Chamberlain’s death was multiple injuries sustained in a motor vehicle incident in which she was the driver.

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: Amanda Reeve Carly Cooper of Freedom Insurance Donna Filippich, St Vincent’s Health Clare Rowan, Transport Accident Commission Paul Younis, Department of Transport Michael Kyriakakis, VicRoads Leading Senior Constable Rohan Clapham

AUDREY JAMIESON CORONER Date: 22 May 2020 9 of 9