Finding into death of Antoine Alam

IN THE CORONERS COURT Court Reference: COR 2019 1064

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 20 January 2021' Findings of: Caitlin English, Deputy State Coroner Deceased: Antoine Alam Date of birth: 13 March 1937 Date of death: 26 February 2019 Cause of death: l(a) Injuries sustained in a motor vehicle collision (pedestrian) Place of death: Alfred Hospital, 55 Commercial Road, Melbourne, Victoria

! This document is an amended version of the Finding into Death Without Inquest of Antoine Alam dated 12 August

2020. A correction to paragraph 25 has been made pursuant to section 76(c) of the Coroners Act 2008 (Vic).

INTRODUCTION

1. Antoine Alam was an 81-year-old man who lived with his wife, Leila, in North Geelong at

the time of his death.

2. Mr and Mrs Alam had been married for 48 years. They masried and welcomed their two

sons in Lebanon before migrating to Australia in 1977.

3. Mr Alam passed away on 26 February 2019 after sustaining injuries in a motor vehicle

collision.

THE PURPOSE OF A CORONIAL INVESTIGATION

4. Mr Alam’s death was reported to the Coroner as it appeared to have resulted, directly or indirectly, from an accident or injury, and so fell within the definition of a reportable death in the Coroners Act 2008.

5. The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death and surrounding circumstances. Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death. The purpose of a coronial investigation is to establish the facts, not to cast blame

or determine criminal or civil liability.

6. The Coroner’s Investigator prepared a coronial brief in this matter. The brief includes statements from witnesses, including family, the forensic pathologist, treating clinicians and

investigating officers.

7. I have based this finding on the evidence contained in the coronial brief. In the coronial

jurisdiction facts must be established on the balance of probabilities.”

IDENTITY

8. On 26 February 2019, Fady Alam visually identified his father, Antoine Alam, born 13 March 1937,

9. Identity is not in dispute and requires no further investigation.

? This is subject to the principles enunciated in Briginshaw v Briginshaw. (1938) 60 CLR 336. The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals unless the evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments.

BACKGROUND

Mr Alam’s medical history included treatment for throat cancer, which left him with a husky voice, an abdominal aneurysm, and heart attack. At the time of his death, he had minor ongoing medical issues, which included high blood pressure, cholesterol, back pain, and shortness of breath. He was prescribed medication to assist with these conditions. He also

suffered sleep apnoea and hearing loss and wore glasses for distance.

In 2016, Mr Alam was involved in a minor car accident at home. He thereafter let his driver’s licence expire and the couple started using the local bus network to travel to Corio

Village or Geelong.

Mrs Alam described her husband as a “slow walker” and he required the assistance of a

walking stick. She described Mr Alam’s health as “good for a man of his age”.

CIRCUMSTANCES IN WHICH THE DEATH OCCURRED

On the morning of 26 February 2019, Mr and Mrs Alam intended to cross Thompson Road in North Geelong, in an east to west direction, to catch a bus from the stop on the western side of the road to travel to Corio Village Shopping Centre. The bus stop is directly opposite their house. The couple were familiar with the area and the usual amount of traffic on the road. They used the bus stop on a weekly basis and were careful when crossing the road, often stopping in the middle of the road to check again for oncoming traffic before

proceeding with their journey across the remainder of the road.

Thompson Road runs in a north/south direction. It is a four-lane carriageway road, with two lanes in each direction. A solid continuous white line separates the north and southbound

lanes. It is in good condition. The speed limit is 60 kilometres per hour.

At this time of day, the road was dry, the weather was fine, and there was a medium amount of traffic.

Mrs Alam stated that morning she and her husband walked to the curb and observed that there was no traffic travelling south toward them so they began to cross the road. Once they reached the centre white line, they both stopped. She then looked to her left for any northbound traffic coming toward them. She saw a truck driving toward them in the left-

hand lane and she decided to wait for it to pass. Mr Alam was standing beside her on her

right-hand side. The truck subsequently slowed and came to a stop to let the couple cross the

road. Mrs Alam began to cross the road.

Mrs Alam stated that she had crossed over the right-hand lane and was about to clear the left-hand lane when she heard a bump. When she turned, she saw her husband lying on the ground.

Mr Alam had been knocked to the ground by a Volkswagen on the right-hand side of the northbound lane. After the collision, the driver immediately stopped her car and got out. She stated that she had seen Mrs Alam run across the road and “then suddenly there was a man on the road”. A witness described the Volkswagen swerving in an attempt to avoid colliding

with Mr Alam.

Mr Alam suffered serious injuries as a result of the collision. He was airlifted to the Alfred Hospital where a CT scan revealed he had suffered an unsurvivable neurological injury.

Mr Alam passed away at 7.35pm that evening.

Victoria Police did not find evidence of excessive speed or that the Volkswagen driver otherwise acted negligently. Leading Senior Constable Sam Thorley, Coroner’s Investigator, concluded that the driver was likely momentarily frightened when she saw Mrs Alam running across the road in front of her and failed to see Mr Alam also attempting to cross the road. Her vehicle was inspected but no mechanical faults that could have contributed to the

cause of the collision were found.

CAUSE OF DEATH

22,

On 28 February 2019, Dr Victoria Francis, a Forensic Pathologist practising at the Victorian Institute of Forensic Medicine, conducted an inspection and provided a written report, dated 1 April 2019. In that report, Dr Francis concluded that a reasonable cause of death was

‘Injuries sustained in a motor vehicle collision (pedestrian)’ .

The CT scan revealed complex right skull fractures with subdural and subarachnoid haemorrhage, midline shift, and cerebral oedema. There were also bilateral haemothoraces,

which were significantly larger on the right.

Toxicological analysis of ante mortem specimens identified the presence of citalopram and

ketamine. Toxicological analysis of post mortem specimens identified the presence of

morphine, midazolam, citalopram, atenolol, and ketamine. Citalopram is an anti depressant

medication. The remaining medications were likely administered during medical treatment.

lL accept Dr Francis’s opinion as to cause of death.

COMMENTS PURSUANT TO SECTION 67(3) OF THE ACT

Leading Senior Constable Thorley noted that there was no provision for any person to cross Thompson Road from the east to the west side in the vicinity of the bus stop to which the Alams were attempting to walk. The nearest pedestrian crossing south of the bus stop is at Victoria Street, a distance of approximately 608 metres. The nearest pedestrian crossing north of the bus stop is near the intersection of Vistula Avenue, which is 295 metres away.?

It therefore appeared impractical for any person wishing to cross Thompson Road from east to west, or from west to east, in the vicinity of the collision to utilise either of these

pedestrian crossings.

Leading Senior Constable Thorley conceded it was impractical to have dedicated pedestrian crossings at every bus stop on Thompson Road. However, given the amount of traffic that uses Thompson Road, he opined that a traffic refuge should be installed at the very least, which would afford pedestrians some protection from advancing traffic at the halfway mark.

This may have prevented Mr Alam’s death. I agree and will make a recommendation for this

possibility to be considered.

FINDINGS AND CONCLUSION

Having investigated the death, without holding an inquest, I find pursuant to section 67(1) of the Coroners Act 2008 that Antoine Alam, born 13 March 1937, died on 26 February 2019 at Alfred Hospital, 55 Commercial Road, Melbourne, Victoria, from injuries sustained in a

motor vehicle collision (pedestrian) in the circumstances described above.

3 In the coronial brief, received on 11 September 2019, Leading Senior Constable Thorley advised that the nearest pedestrian crossing north of the bus stop was at Separation Street, which was 623 metres away. On 7 September 2020, I received an email from a member of the public who had read the published finding and noted the closest pedestrian crossing north of the bust stop was in fact Vistula Avenue. I therefore requested Victoria Police to confirm the closest pedestrian crossings to the scene of the collision. Senior Constable Aaron Johnstone advised me on 21 October 2020 that the nearest pedestrian crossing to the north of the collision was at Vistula Avenue, approximately 295 metres away.

Paragraph 25 has been amended pursuant to section 76(c) of the Coroners Act 2008 (Vic) to reflect Senior Constable Johnstone’s advice.

RECOMMENDATIONS

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

connected with the death:

I recommend that the City of Greater Geelong and VicRoads review pedestrian safety along Thompson Road, North Geelong, and consider installing pedestrian crossings or

traffic refuges between the bus stops on the east and west sides of the road.

29, Pursuant to section 73(1) of the Coroners Act 2008, | order that this finding be published

on the internet.

30. I convey my sincere condolences to Mr Alam’s family for their loss.

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

Lilian Alam, senior next of kin Alfred Health

VicRoads

City of Greater Geelong

Leading Senior Constable Sam Thorley, Victoria Police, Coroner’s Investigator.

Signature: a

ZED Cong LA. |

CAITLIN ENGLISH

DEPUTY STATE CORONER Date: 12 August 2020