Deceased
Jason Phillip Gilham
Demographics
27y, male
Coroner
Coroner John Olle
Date of death
2018-12-15
Finding date
2021-01-14
Cause of death
Immersion in the setting of a motor vehicle incident
AI-generated summary
Jason Gilham, 27, died from immersion when the vehicle he was a passenger in left the Western Ring Road at a bend and became submerged in a dam. The driver (also deceased) had a history of vasovagal syncope investigated in 2011 with normal cardiac findings, but exhaustive investigation could not definitively establish why the vehicle left the road. The coroner ruled out mechanical failure, alcohol (passenger had consumed 2 beers), driver distraction, and concluded it unlikely the driver suffered a medical event. Key clinical lessons: syncope risk stratification and follow-up completion are important even when initial investigations appear normal; unexplained loss of consciousness while driving requires thorough investigation and may warrant driving restrictions pending further evaluation.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Drugs involved
IN THE CORONERS COURT Court Reference: COR 2018 6288
Findings of:
Deceased:
Date of birth:
Date of death:
Cause of death:
Place of death:
Form 38 Rule 63(2) Section 67 of the Coroners Act 2008
1(a) IMMERSION IN THE SETTING OF A MOTOR
I. On 15 December 2018, Jason Gilham was 27 years old when he died in a motor vehicle © accident. Jason was a passenger in the vehicle which was being driven by his best friend,
Bradley Dobney, who also died in the accident.
. in November 2018 and had only lived at the property for approximately two weeks before they left for a holiday to Thailand. Jason’s father said that Carla recently discovered Jason had purchased an engagement ring on layby which had one final payment outstanding. From all
accounts, the young couple were very happy and excited to start their life together.
ethic and was noted to be a dedicated employee.
He loved to laugh and joke and was very social. Jason had a tightknit group of friends, most of whom he had known since childhood including Brad, as well as Liam Hill, Mike Batten and Tom Greaves. Jason and Brad met growing up when they played cricket together, and Jason’s parents said the two became closer later in life due to their mutual love of cars. Brad, Jason,
Liam, Tom and Mike all shared this passion, and would often work on cars together.
from vacation.
unnatural or violent or result from accident or injury.
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.
Under the Act, coroners also have the important functions of helping to prevent deaths and promoting public health and safety and the administration of justice through the making of comments or recommendations in appropriate cases about any matter connected to the death
under investigation.
The Victoria Police assigned an officer to be the Coroner’s Investigator for the investigation of Jason’s death. The Coroner’s Investigator conducted inquiries on my behalf, including taking statements from witnesses — such as family, the forensic pathologist, treating clinicians and
investigating officers — and submitted a coronial brief of evidence.
This finding draws on the totality of the coronial investigation into the death of Jason Gilham, including evidence contained in the coronial brief. Whilst I have reviewed all the material, I will only refer to that which is directly relevant to my findings or necessary for narrative clarity.
In the coronial jurisdiction, facts must be established on the balance of probabilities.
Circumstances in which the death occurred
On 15 December 2018, at approximately 7:00pm, Brad drove himself and Jason to Lazy Moe’s restaurant in Caroline Springs, where they met up with Mike and Tom. The group had dinner together and Brad drank one Corona beer and one James Boags light beer and Jason had two
beers.
The group finished their meal at approximately 8:20pm. According to Mike, the four young men went outside to see Brad’s new car and talked for another 10-15 minutes before leaving.
As far as Mike and Tom were aware, Brad was driving himself and Jason to Jason’s house in
Hoppers Crossing to work on a car and have a few drinks.
1 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,
13,
Both Tom and Mike said that after leaving the restaurant they pulled up next to Brad and Jason on Chisholm Drive at the intersection of Ballarat Road. Tom and Mike turned left, while Brad and Jason tumed right onto Ballarat Road.
After 8:30pm, a witness reported seeing a car which matched the description of Brad’s Mercedes Benz four-wheel drive travelling along the Western Ring Road at Derrimut past McDonald’s and 7 Eleven. The witness stated she noticed there were two young men in the
car,
At approximately 8:45pm, a male driver on the Western Ring Road said he noticed a “newish white four-wheel drive” in the left-hand lane as he approached the Princes Freeway, Geelong exit. The witness stated he was travelling at 90km per hour and noted that the white four-wheel drive was slightly ahead and travelling approximately 80km per hour. According to the witness, as both cars approached a right-hand bend at the entrance to the Princess Freeway, the white four-wheel drive failed to turn and continued straight. He said the vehicle “didn’t appear to turn at all, just straight, straight, straight”. The car mounted the curb striking a chevron sign,
before disappearing down the grassed embankment.
A female driver and her daughter also observed the white Mercedes four-wheel drive depart the
oo
road and drive onto the embankment followed by “a big cloud” of either dust or water.
Concerned by what they observed, they stopped and contacted emergency services.
Victoria Police officers, Sergeant Evan Brown (formerly Leading Senior Constable Brown) and Senior Constable Ford, arrived at the scene at approximately 9:00pm, followed shortly by Ambulance Victoria paramedic, Stewart MacGregor. While searching the area, Sergeant Brown walked up the embankment adjacent to the Western Ring Road Geelong off ramp and noticed a road sign had been pushed over and there were fresh tyre marks in the grass. Sergeant Brown, SC Ford and Paramedic MacGregor followed the tyre marks down the embankment to the edge of a dam, where they discovered a vehicle upside down and submerged in the water.
Only the car’s two rear wheels were visible above the waterline.
Sergeant Brown and Paramedic MacGregor entered the water to check for occupants in the vehicle. The water was noted to be “particularly dirty” and was subsequently described by a Victoria Police Search and Rescue Squad officer as “black water” with no visibility.. The dam was reed-filled, which made it difficult to move through. On reaching the upturned vehicle, Sergeant Brown recognised the car to be a Mercedes Benz. Paramedic Macgregor and Sergeant
Brown searched underwater and tried to open the car’s door handles, however, the doors
appeared to be locked. Sergeant Brown discovered the rear hatch open, and reached inside, however, was unable to locate anyone. There were no signs of life detected in the vehicle and they became concerted that a substantial amount of time had passed since the incident was reported, Ultimately, they were unable to gain entry to vehicle or reach its occupants while it
was in the water.
Additional police officers arrived on scene including the Victoria Police Search and Rescue Squad and a Police Air Wing approached overhead. State Emergency Services attended and provided additional lighting. Following an initial assessment with the assistance of Search and Rescue Squad members, the decision was made to remove the vehicle from the water, rather than dive on it. The car was subsequently towed from the water with the assistance of police
divers and a tow truck.
Once removed from the water, two deceased males were located inside the vehicle and later identified as Bradley Dobney and Jason Gilham. Neither male was wearing a seatbelt, and they were both located in the back section of the car. Jason’s legs were protruding from the damaged glass roof and his left arm was noted to be wrapped around Brad, as if he were giving him a
hug.
Victoria Police incident investigation
Attending police officers including Sergeant Brown and SC Ford examined and measured the scene. The scene was photographed, and statements obtained from witnesses. The conditions
were noted to be dry with good visibility, however, the light was fading. .
The incident occurred at the Western Ring Road/Princes Freeway interchange in Laverton North. Prior to the interchange, the Western Ring Road is a four-lane roadway bordered by emergency stopping lanes on both sides. At the interchange, the road subsequently divides for Geelong bound traffic to enter the Princess Freeway to the right, and city bound traffic to enter the West Gate Freeway to the left. The entrance to the Princess Freeway to Geelong transitions to a two-lane carriage way bordered by paved shoulders. There is a right-hand curve in the road and the left-hand lane is bordered by a grassed reserve which leads down a sloping embankment to adam. At this section of road, the speed limit reduces from 100km per hour to 80km per hour. There are also two 70km advisory signs at the bend followed by seven yellow and black chevron arrow signs signalling a curve in the road.. At the fourth chevron sign, a guard rail lines
the left-hand side of the road.
Witnesses reported that prior to the incident, the white Mercedes Benz four-wheel drive was travelling southbound in the left-hand lane, adjacent to the grassed reserve. Tyre scuff marks were present on the paved shoulder where the vehicle left the road, followed by rolling tyre prints on the grassed reserve which led down to where the vehicle was located. The markings confirmed witness accounts that the vehicle had failed to negotiate the right-hand bend in the road, and instead continued straight, over the paved shoulder of the road and onto the grassed
reserve.
Sergeant Brown inspected the paved road surface of the Western Ring Road where the vehicle veered off track and noted no signs of skid marks, yaw marks, debris, disturbed gravel or any other evidence which would have indicated an incident occurring prior to the vehicle leaving
the road. He stated that there was no evidence of the driver having taken evasive action, and
‘that the vehicle continued in a straight line until it entered the dam. The tyre markings indicated
the tyres rolled over the surface without braking, acceleration or a change in steering direction.
Gouge marks were noted, revealing that the vehicle had been airborne and landed before entering the dam. Sergeant Brown opined that the vehicle became upturned on impact when the front of the vehicle slowed as it entered the water, while the rear of the vehicle maintained
momentum.
Following removal from the water, Sergeant Brown inspected the vehicle on land and noted all doors to be locked, the boot/hatch open and both rear windows were wound down. The rear seats were in the upright position, preventing access to the boot area. The doors were able to
be unlocked by pulling on the handle from inside the vehicle.
The vehicle was retained by Victoria Police and later underwent a mechanical inspection by mechanical investigator, Dale Woodland, of the Collision Reconstruction and Mechanical Investigation Unit (CRMIU). Following inspection, Mr Woodland concluded that the vehicle was in ‘as new’ condition prior to the collision, and the examination did not reveal any
mechanical fault or condition which would have caused or contributed to the collision.
Sergeant Brown subsequently requested Detective Leading Senior Constable Michael Hardiman of the CRMCIU review the incident to attempt to determine the speed of the Mercedes Benz when it left the road and travelled down the embankment. DLSC Hardiman reviewed the traffic report, measurements and photographs taken. He noted that there were ‘rolling tyre prints’ present (a tyre mark left by a tyre that is simply rotating and is neither sliding nor slipping), and stated it was not possible to tell from a rolling tyre print whether a vehicle was under breaking, accelerating or was simply rolling. He stated however that any
braking was not sufficient to cause the tyres to lock, and any acceleration was not significant enough to cause the tyres to spin. He also noted that the direct path of the tyre prints indicated the driver did not input any sideways steering. DLSC Hardiman also attempted to calculate the speed of the vehicle by retrieving the vehicle’s Event Data Recorder information, however, the
data could not be downloaded by Victoria Police.
Ultimately, DLSC Hardiman was unable to give an opinion as to the speed of the Mercedes Benz as it left the road and journeyed down into the dam. Consequently, the speed of the vehicle
at the time of the incident could not be determined.
Sergeant Brown also made enquiries with the vehicle manufacturer, Mercedes Benz, however, the information provided did not assist, save for the manufacturer suggesting that the impact was insufficient to meet the deployment criteria to instigate a crash signal which would have resulted in safety features such as airbag deployment and automatic door unlocking to allow
the doors to be opened from the outside
Identity of the deceased
On 19 December 2018, Jason Phillip Gilham, born 8 June 1991, was visually identified by his
mother, Leasa Gibson.
Medical cause of death
Forensic Pathologist Dr Melanie Archer from the Victorian Institute of Forensic Medicine (VIFM), conducted an autopsy on 20 December 2018 and provided a written report of her findings dated 9 July 2019,
Dr Archer stated that the post-mortem examination revealed no injuries that would have caused
death in isolation, and the most likely mechanism of death was drowning. She further noted that there was bruising to the scalp, indicating that Jason hit the top and left side of his head and forehead. It was therefore possible he was unconscious at the time of immersion due to concussive head injury (there was no evidence of brain trauma). She reported there were a number of lacerations and incised injuries mainly involving the hands and feet and some may have been associated with the initial vehicle impact, but stated the possibility was raised that some may have been sustained in attempts to escape the vehicle after impact. There was no
evidence of natural disease that could have caused or contributed to death.
chloride, glucose, creatinine and urea within normal post mortem limits.
setting of a motor vehicle incident’.
Medical investigations
The lack of evidence suggesting a deviation or correction in the vehicle’s path is significant.
Further, Brad was a responsible, cautious driver. It is unlikely he would have intentionally taken his eyes off the road, whilst negotiating a sweeping bend. I therefore consider driver distraction an unlikely cause of the incident. Consequently, attention turned to whether Brad
may have suffered a medical episode while driving which caused him to veer off the road.
In an email to the Court, Jason’s mother, Leasa Gibson, expressed concerns that Brad had a medical condition which affected his ability to drive and believed this may have caused the incident. During the investigation, Brad’s family and friends reported he had previously suffered fainting episodes which were investigated by a cardiologist, Dr Susan Corcoran, in
Consequently, I sought the assistance of the Coroner’s Prevention Unit (CPU) to review Brad’s medical record. and consider whether any medical condition, including previously
diagnosed syncope could have caused or contributed to the incident.
Available information
(a) 5 visits to Westgate Health, largely for minor medical conditions. At one visit (27 September 2017) he was in the toilet at the doctors and had blacked out after standing
up. He described feeling dizzy beforehand and lost consciousness for 30 secs or so. His
? The CPU assists the Coroner with research in matters related to public health and safety and in relation to the formulation of prevention recommendations. The CPU also reviews medical care and treatment in cases referred by the Coroner and is comprised of health professionals with training in a range of areas including medicine, nursing, public health and mental health.
fall against the wall left a hole in the plaster. This was in the setting of having a vomiting
illness. Subsequent observations and an ECG were normal.
(b) Review by Dr Susan Corcoran (Cardiologist) in 2011. This occurred because of a family history in two older sisters, of “recurrent neutrally mediated syncope and upper normal
QT? intervals”.
(a) A report by Bradley’s parents of him fainting when visiting a friend with a broken arm at the age of 15.
(b) —_ Reports by friend, Liam Hill, of:
(i) A blackout in October 2013 that occurred without warning whilst at a BBQ.
Alcohol had been consumed at this time.
(ii) A blackout in June 2017 that occurred when Bradley stood up from a table and fell over. Her looked momentarily vague. No alcohol was involved on this
occasion.
(iii) | A reported episode whist driving in 2014, although it is not clear if this was a blackout.
(a) A history of classic neurally mediated syncope associated with prolonged standing or seeing sick or injured friends/relatives. These episodes were not suggestive of a
disturbance of heart rhythm as mechanism.
(b) A normal ECG with a normal QT interval.
3 QT interval is the time from the start of the Q wave to the end of the T wave of the ECG. It represents the time taken for ventricular depolarisation and repolarisation. The QT interval shortens at faster heart rates and lengthens at slower heart rates.
Congenital long QT syndromes are associated with an increased risk of ventricular arrhythmias, especially ‘Torsades de Pointes’ and sudden cardiac death.
Congenital short QT syndrome has been found to be associated with an increased risk of paroxysmal atrial and ventricular fibrillation and sudden cardiac death, Some medications are known to prolong the QT interval and result in cardiac arrhythmias.
QT interval pathology is not identifiable at post-mortem examination.
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(c) A normal QT interval at rest but does not shorten the QT interval during normal sinus arrhythmia’.
The medical record also revealed Dr Corcoran subsequently arranged for Bradley to undergo a stress test to evaluate his QT dynamics further with a review appointment in 3 months. She also advised him to avoid QT prolonging drugs and electrolyte disturbances. However, Dr Corcoran’s notes recorded that Bradley cancelled the stress test and 2 review appointments in
March 2011 and she had no further contact with him.
Bradley’s ECG from 27 September 2017 was reviewed and considered to be normal by two other cardiologists, Professor Jitendra Vohra and Dr Mark Perrin, who would both be considered experts in the field of cardiac rhythm disorders. Both cardiologists assessed the ECG as having a normal T-wave morphology and a normal QT interval, with the ECG
considered to be overall with normal limits.
Whilst Bradley did not undergo further testing as recommended by Dr Corcoran, it is unlikely that he. had a congenital QT syndrome that.put him at risk of sudden cardiac death. As Dr Corcoran described, his previous collapses appeared to be typical for neurally mediated syncope (NMS) and his ECG was essentially normal.
NMS is the most common form of fainting. It is benign and rarely requires medical treatment and is more common in children and young adults, although it can occur at any age. It happens when the part of the nervous system that regulates blood pressure and heart rate malfunctions in response to a trigger, such as emotional stress or pain. NMS typically happens while standing and is often preceded by a sensation of warmth, nausea, light-headedness, tunnel vision or visual "grey-out.". Placing the person in a reclining position restores blood flow and
consciousness.
Syncope can also be related to certain physical events, such as violent coughing, and this has been used as an explanation for similar events in the past. However, there is no indication that
Bradley was unwell at the time of the incident.
Conclusion
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Whilst it is unlikely that Bradley had a sudden cardiac event due to a congenital cardiac
electrophysiological problem, it is possible that he suffered syncope for some other reason.
However, when considering the findings of Dr Corcoran and the general circumstances in which Bradley had previously fainted (whilst unwell, associated with alcohol or witnessing unwell/injured persons), it would be speculative to conceive of a scenario that could have
provoked an NMS type response in Bradley whilst driving.
Consequently, I am unable to conclude that Brad suffered a medical event which caused or
contributed to the collision.
Installation of barriers at the incident location
A short distance from where Brad’s car left the roadway, there is a roadside safety barrier which borders the curve in the road at the Western Ring Road Geelong-bound exit ramp. Notably, the guardrail does not cover the area where Brad’s car left the road and the car was able to travel unimpeded down the embankment. Consequently, my Coronial Investigator proposed 1 make a recommendation that the existing safety barrier be extended to prevent vehicles from leaving the road at that section of road. It was also suggested that an additional barrier be installed along the road on the northern side of the grassy reserve to protect Melbourne bound traffic.
Brad’s. family strongly supported this recommendation and I considered the recommendation
sound and reasonable.
While the suggested recommendation focussed on the incident location, I also considered there may have been broader prevention opportunities. Accordingly, I consulted with the Department of Transport and sought their input in respect to a proposed recommendation that ‘...safety
barriers be installed in the vicinity of any waterways to prevent similar events in future.’
In response to the Court’s correspondence, Executive Director Metro North West, Alan Fedda, of the Department of Transport advised that, following the incident, they conducted a review of the existing road infrastructure (including the existing roadside safety barrier) and concluded that the existing infrastructure did not breach the applicable safety and design standards.
However, Mr Fedda further noted that the current approach adopted by Victoria, ‘the safe system approach’, provides for broader indicators in the assessment of road hazards.
Consequently, regarding the incident site, Mr Fedda stated, “this approach would require further consideration to the road geometry, steep roadside embankment, and nearby body of water that is likely to warrant further extension to the existing nearby barrier”. Mr Fedda further noted that the Austroads Guide to Road Design Part 6 is currently being updated to further align with the safe system approach for the treatment of hazards to further minimise the risk of fatalities
and serious injuries.
Significantly, Mr Fedda stated that “this improvement to extend the nearby barrier will be
considered for funding in a future program once the West Gate Tunnel Project is completed”.
In response to my specific recommendation which extended more broadly than the incident site,
the Department of Transport considered that such a recommendation would not be appropriate
as:
(a) “the definition of waterways captures a range of bodies of water, not all of which are relevant to the road network, and
(b) A broad-brush recommendation such as this does not recognise the risk-based
approach that DOT takes in relation to road safety”.
The Department of Transport accurately pointed out that the proposed recommendation and use of the language ‘waterways’ would include many water environments including wetlands, of which there are 35,000 in the State, and this would pose funding and environmental challenges.
An excerpt from the Austroads guide to road design relating to hazard identification was included with Mr Fedda’s correspondence, and listed hazard examples which included ‘bodies
of water’ as the relevant hazard classification.
I consider the Department’s response to my proposed recommendation eminently reasonable, and I have therefore framed my recommendation in line with the preferred safe system approach which appropriately applies a risk-based approach to identifying and assessing road hazards,
including ‘bodies of water’.
Implementation of automatic unlocking sensors in vehicles
Sergeant Brown also proposed a recommendation be made that ‘car manufacturers worldwide consider implementing auto unlocking sensors for inverted and submerged vehicles.’ In considering the recommendation, ] consulted with the Federal Chamber of Automotive Industries (FCAT) and sought their feedback regarding making a coronial comment that manufacturers selling new vehicles in Australia consider implementing auto unlocking sensors
when a car is inverted and/or submerged in water.
As part of their response to the proposal, the FCAI advised that Australia contributes to the
development of global vehicle regulations through their participation in the World Forum for
Harmonisation of Vehicle Regulations and has a policy of harmonisation whereby the
Australian Design Rules (ADRs) are aligned with the relevant United Nations Economic
Commission for Europe regulations. They noted that the alignment of the majority of ADRs
ensures vehicles offered for sale in Australia are equipped with the latest available safety technologies. The FCAI further commented that Australia “represents a very small percentage of the overall vehicle market, with overall sales representing around 1% of global production”.
Consequently, they stated that Australia is normally a “technology taker”, not a “technology
maker”.
The FCAI explained that the international approach to consideration of mandating a new technology would require consideration of incidence rate of this type of event and a cost benefit analysis worldwide. They opined that the cost benefit analysis would make the adoption of such an ADR or international standard unlikely given the rarity of this type of incident.
Consequently, I agree that such a recommendation would have limited utility as it would be
unlikely to be implemented as a standard safety feature in Australian vehicles
Having investigated the death of Jason Phillip Gilham and having considered all of the available
evidence, I am satisfied that no further investigation is required Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings:
(a) the identity of the deceased was Jason Phillip Gilham, born 8 June 1991;
(b) the death occurred on 15 December 2018 at the Western Ring Road, Laverton North,
Victoria, from immersion in the setting of a motor vehicle incident; and
(c) the death occurred in the circumstances described above.
Regrettably, despite exhaustive investigations, the cause of the vehicle leaving the roadway in this case cannot be identified. The evidence suggests that Brad was a responsible driver who seemed well, and both men were in good spirits immediately prior to the incident. No concerning driving behaviour was witnessed before the car veered off the road, and there was no evidence to suggest that driver distraction was a contributing factor. It was evident that the two friends tried their best to escape the vehicle, and although they were unsuccessful,
comforted each other.
I commend and acknowledge the professionalism of Victoria Police and Ambulance Victoria first responders, and members of the Victoria Police Search and Rescue Squad. Their determined efforts to extract the occupants in extremely challenging circumstances, though unsuccessful, were remarkable.
COMMENTS Pursuant to section 67(3) of the Act, I make the following comments connected with the death:
to consider the project as a high priority.
RECOMMENDATIONS Pursuant to section 72(2) of the Act, I make the following recommendations:
(a) Using the risk-based ‘safe system approach’, the Department of Transport should conduct a review of Victorian roads in the vicinity of “bodies of water’, to identify and consider whether
safety barriers should be installed or extended to protect against potential water hazards.
I convey my sincere condolences to Jason’s family and friends for their loss.
Pursuant to section 73(1B) of the Act, I order that this finding be published on the Coroners Court of
Victoria website in accordance with the rules.
I direct that a copy of this finding be provided to the following: Carla Rainone, Senior Next of Kin
Leasa Gibson and Scott Gilham
Karen Macdonald, Department of Transport
Tony Weber, Federal Chamber of Automotive Industries
Sergeant Evan Brown, Coroner’s Investigator
Signature:
Date: 14 January 2021
NOTE: Under section 83 of the Coroners Act 2008 (‘the Act’), a person with sufficient interest in an investigation may appeal to the Trial Division of the Supreme Court against the findings of a coroner in respect of a death after an investigation. An appeal must be made within 6 months after the day on which the determination is made, unless the Supreme Court grants leave to appeal out of time under section 86 of the Act.
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