Deceased
Jon Gorr
Demographics
62y, male
Coroner
Coroner David Ryan
Date of death
2021-09-28
Finding date
2023-11-17
Cause of death
head, chest and pelvic injuries sustained in a cycle versus car motor vehicle incident
AI-generated summary
Jon Gorr, aged 62, died from head, chest and pelvic injuries sustained in a collision between his bicycle and a car driven by William Bennett on Tooram Road, Allansford, Victoria on 28 September 2021. The coroner was unable to determine whether Gorr entered Tooram Road from Maria Street or from further south. Expert collision reconstruction evidence indicated it was more likely he was travelling straight on Tooram Road rather than turning from Maria Street, though both scenarios were possible. The coroner found insufficient evidence to conclude that Gorr failed to give way, reversing an earlier adverse finding that had caused distress to his family. No errors in medical management were identified; the paramedic response was appropriate and Mr Bennett's vehicle was mechanically sound. The death resulted from unavoidable traffic circumstances rather than preventable clinical or driver error.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
IN THE CORONERS COURT COR 2021 005158 OF VICTORIA AT MELBOURNE FINDING INTO DEATH FOLLOWING INQUEST Form 37 Rule 63(1) Section 67 of the Coroners Act 2008
INQUEST INTO THE DEATH OF JON GORR Findings of: Coroner David Ryan Delivered on: 17 November 2023 Delivered at: Coroners Court of Victoria 65 Kavanagh Street, Southbank, Victoria Inquest hearing dates: 30 October 2023 Counsel Assisting the Coroner: Susanna Locke of counsel Marion Gorr: Stephanie Wallace of counsel William David Bennett: Damian Sheales of counsel Keywords: Motor vehicle and cycling incident – collision reconstruction
On 28 September 2021, Jon Gorr was 62 years old when he died from injuries sustained when he was struck by a car while cycling. At the time of his death, Mr Gorr lived in Allansford with his wife, Marion Gorr.
In Coronial Impact Statements delivered to the Court by his family, Mr Gorr is fondly remembered as a loving, caring and eccentric man with a warm sense of humour and a brilliant intellect.
Mr Gorr’s death was reported to the Coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (the Act). Reportable deaths include deaths that are unexpected, unnatural or violent or result from accident or injury.
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.
A coroner must not include in a finding or comment any statement that a person is, or may be, guilty of an offence.
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.
Victoria Police assigned an officer to be the Coroner’s Investigator for the investigation of Mr Gorr’s death. The Coroner’s Investigator conducted inquiries on my behalf, including taking statements from witnesses – such as family, first responders, the forensic pathologist and investigating officers – and submitted a coronial brief of evidence.
On 25 May 2022, I delivered a finding pursuant to section 67 of the Act in relation to Mr Gorr’s identity, his cause of death and the circumstances in which his death occurred. Relevantly, the finding recorded that I was satisfied that it was likely that Mr Gorr failed to adequately give way at the intersection where the incident occurred.
On 12 September 2022, Ms Gorr filed an application with the Court under section 77 of the Act seeking an order that my findings delivered on 25 May 2022 should be set aside and the investigation re-opened. In her application, Ms Gorr stated that I made an adverse finding against her husband without affording her the opportunity to be heard. Further, she stated that had she known I was considering making an adverse finding in relation to her husband, she would have sought further investigation into the circumstances of his death.
On 4 November 2022, I determined that it was appropriate to set aside the finding regarding the circumstances of Mr Gorr’s death. I was satisfied that Ms Gorr was not provided with sufficient opportunity to make submissions or adduce further evidence in relation to any adverse finding that I made in relation to her husband.
Since the investigation has been re-opened, further witness statements have been obtained including from Detective Sergeant Dr Jenelle Hardiman of the Victoria Police Collision Reconstruction and Mechanical Investigation Unit (CRMIU). Further, the mobile telephone which Mr Gorr was carrying with him at the time of the incident was analysed by Victoria Police.
I have also considered submissions and other material forwarded to the Court by Ms Gorr, including an expert report from Dr George Rechnitzer.
MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Circumstances in which the death occurred
In her statement to police, Ms Gorr reported that she had offered to drive her husband to Hopkins Point Road, however he declined and advised that he would take the Princes Highway “as it is safer as there is a hard shoulder”.2
Ms Gorr suspected that he would cycle past Hopkins River to look at the ducks and then continue onto Tooram Road to return home. She stated that “the street he would have come out of could well of been Maria Street as that is by the river and leads on to Tooram Road and then he would have been riding back to our house”.3
2 Statement of Marion Gorr dated 28 October 2021.
3 Statement of Marion Gorr dated 28 October 2021.
wearing a helmet and a fluorescent orange backpack.4 She did not see if he rode straight onto Tooram Road or whether he turned onto Catherine Street.5
A short time later, William David Bennett was driving in a northerly direction along Tooram Road in his Mitsubishi utility. In his first statement to the Court, Mr Bennett recalled that there were no other cars on the road in front of him. The relevant section of Tooram Road is divided into two lanes of traffic for north and southbound travel and has a sign posted speed limit of 60 kilometres per hour.
Mr Bennett stated that as he passed the intersection with Maria Street—at which road users are directed by a sign to give way prior to entering into Tooram Road—Mr Bennett heard a “large thud” and observed a “black blur” to the left of his car in his peripheral vision. Mr Bennett “looked in the rear-view mirror” and saw “a person and bike lying on the road”. He then stopped his car on the side of the road in front of a park and went to render assistance.6
When spoken to by Victoria Police directly after the incident, Mr Bennett said that Mr Gorr “rode out from that street and it was just like I didn’t even see him, he’s just like hit before I even saw him right on that corner”.7
In a further statement to the Court, Mr Bennett stated that he “did not see Mr Gorr enter Tooram Rd from Maria Street on his bicycle at any time prior to the collision. The road way was clear so I did not see any vehicles, people or bicycles on Tooram road as I drove along it, on that day”.8
Shortly prior to the collision, Ernest Fary was in the living room of his home on Tooram Road when he heard “a loud metallic sound”. Mr Fary went outside to investigate and observed a damaged bicycle on the road between three to four metres north of the intersection of Maria Street and Tooram Road. He then observed Mr Gorr lying on Tooram Road beside a bus shelter and Mr Bennett’s car between eight to ten metres away.9 4 Statement of Keira Gordon dated 1 November 2021.
5 Statement of Keira Gordon dated 20 December 2022.
6 Statement of William Bennett dated 22 February 2022.
7 BWC footage of Senior Constable Mark Kirby; In the footage of the discussion, Mr Bennett can be seen gesturing towards Maria Street.
8 Statement of William Bennett dated 6 January 2023.
9 Statement of Ernest Fary dated 26 November 2021.
Also at this time, Helen Goddard was doing some gardening in the front yard of her home on Tooram Road when she heard “an almighty bang, like a piece of corrugated iron falling off a truck”. She looked up and observed Mr Gorr lying on Tooram Road “not far” from the intersection with Maria Street. Ms Goddard observed Mr Bennett walking back from his vehicle towards Mr Gorr. She contacted emergency services at 2.39pm.10
Shortly after the collision, Steven Schrader came upon the scene when he was driving south along Tooram Road. He also contacted emergency services at 2.39pm and moved his car to block off northbound traffic until Victoria Police arrived. The following day, he made a report to Crime Stoppers which recorded that “the driver mentioned that he was driving on Tooram Road and the push bike rider pulled out in front of him from a side road (unsure which)”. However, in his statement provided to the Court dated 27 January 2023, Mr Schrader reports that he does not remember any discussion with Mr Bennett.11
Shortly after the collision, an off-duty nurse, Amanda Preece, came upon the scene when she was driving north on Tooram Road. She stopped to render assistance and Ms Goddard handed over her phone so Ms Preece could communicate with emergency services while she tended to Mr Gorr and awaited the arrival of paramedics from Ambulance Victoria. Ms Preece confirmed with emergency services that Mr Gorr was breathing but unconscious and she tried to stem the bleeding from Mr Gorr’s head injury. Mr Fary held up a towel to shield him from the sun and he observed his helmet on the nearby nature strip.12
After handing her phone to Ms Preece, Ms Goddard brought a drink of water to Mr Bennett who was sitting on the fence in the adjacent park on Tooram Road. She recalled that Mr Bennett said to her, “he just rode out in front of me”.13
Ambulance Victoria paramedics arrived at approximately 2.53pm and observed that Mr Gorr had sustained multiple injuries, including a severe head wound, which were noted to be “possibly consistent” with having gone underneath the vehicle post-impact. He was recorded as having a 10 Statement of Helen Goddard 25 January 2023; ESTA records.
11 Statement of Steven Schrader dated 27 January 2023; ESTA records.
12 Statement of Amanda Preece dated 28 January 2023; ESTA records; Statement of Ernest Fary dated 26 November 2021.
13 Statement of Helen Goddard 25 January 2023.
Glasgow Coma Scale (GCS)14 score of 3 and laboured breathing.15 Ms Preece continued to assist in the emergency response and observed that Mr Gorr “had some headphones on that were under his T-Shirt with the ear parts coming out of the neck part of the T-Shirt”. She stated that she could not recall seeing them in his ears.
Mr Gorr was intubated and responding paramedics administered oxygen therapy and assisted ventilations, applied a pelvic splint, and tried to stabilise him for transport to hospital by helicopter. Due to a delay in the arrival of the helicopter, paramedics decided to transfer him by road to Warrnambool Base Hospital and cancelled their request for an Air Ambulance.16
While being loaded into the ambulance a short time later, Mr Gorr went into cardiac arrest and paramedics commenced cardiopulmonary resuscitation (CPR) and applied a defibrillator. Despite exhaustive resuscitation efforts, Mr Gorr remained unresponsive and paramedics considered his injuries were too extensive to continue CPR. He was subsequently pronounced deceased at 3.30pm.17
Mr Bennett underwent a preliminary breath test and oral fluid test by Victoria Police at the scene, which were negative for alcohol and illicit drugs. He later provided a blood sample for toxicological analysis, the results of which were similarly negative for alcohol and illicit drugs.18 Further, toxicological analysis of post-mortem samples of Mr Gorr’s blood did not detect any alcohol or other drugs.
Victoria Police conducted a “door knock” in the area and, apart from Mr Bennett, no witnesses have been located who saw the collision or who can confirm whether Mr Gorr turned into Tooram Road from Maria Street or whether he entered Tooram Road further south.
14 The Glasgow Coma Scale (GCS) is a neurological scoring system used to assess conscious level. The GCS is comprised of three categories; best eye response, best vocal response and best motor response. The GCS is scored out of 15, with a score of 15 indicating a normal level of consciousness.
15 Ambulance Victoria, Electronic patient care record completed by MICA Single Responder dated 28 September 2021.
16 Ambulance Victoria, Electronic patient care record completed by two-person Warrnambool paramedic crew dated 28 September 2021; Ambulance Victoria, Electronic patient care record completed by Rotary Wing Aircraft crew dated 28 September 2019; 16 Statement of Amanda Preece dated 28 January 2023.
17 Statement of Shane Hammond dated 22 December 2021; Ambulance Victoria, Electronic patient care record completed by two-person Warrnambool paramedic crew dated 28 September 2021.
18 Statement of Leading Senior Constable Mark Kirby dated 2 December 2021.
Victoria Police’s analysis of Mr Gorr’s mobile phone, which he was carrying at the time of the collision, did not enable them to confirm the route he took immediately before the collision.
Police examined the surrounding area to the collision and determined that the point of impact was approximately 10.1 metres north of the centre line on Maria Street. Mr Gorr’s bicycle was approximately 9.1 metres north of this point and he had been thrown a further six metres north.
The absence of tyre marks on the road surface at the point of impact suggested that Mr Bennett did not observe Mr Gorr immediately prior to impact in order to brake or take evasive action.19
Dr Hardiman conducted a collision reconstruction, assisted by a Traffic Incident System Report, scene diagram and photographs. She did not attend the scene. Having observed the damage sustained by Mr Gorr’s bicycle and Mr Bennett’s car, Dr Hardiman formed the opinion that Mr Gorr’s bicycle was impacted from the rear by the front passenger side of Mr Bennett’s car. She was unable to determine whether Mr Gorr was travelling along Tooram Road at the time of the collision, or whether he had turned onto Tooram Road from Maria Street. Dr Hardiman estimated that at the time Mr Bennett struck Mr Gorr, he was travelling between approximately 48 to 50 kilometres per hour.20
Dr Hardiman provided a further statement to the Court after the investigation was re-opened under section 77 of the Act and was specifically asked to provide an opinion, if possible, as to whether Mr Gorr entered Tooram Road from Maria Street or prior to Maria Street. Dr Hardiman answered that question as follows: “Taking into account the road geometry, the damage to the bicycle, the damage to the vehicle, the gouges at the AOI (area of impact) and the likely POI (point of impact), it is more likely that the cyclist was travelling straight on Tooram Road rather than having turned left from Maria Street immediately prior to the collision. However, it is not impossible that the cyclist turned left from Maria Street. The likelihood of the cyclist having turned left from Maria Street is dependent on the travel path and speed of the bicycle, neither of which can be assured. I would best describe the likelihood of the cyclist 19 Statement of Leading Senior Constable Mark Kirby dated 2 December 2021.
20 Statement of Detective Sergeant Dr Jenelle Hardiman dated 31 October 2021.
having turned left from Maria Street as less likely than having been travelling straight, but not unlikely.”21
Earlier in her supplementary report, she had clarified that the AOI is the first evidence of a collision at the scene, which in this case was the gouge marks on the road which were located on Tooram Road, 10.1 metres north of the centre line of the intersection with Maria Street. She noted from research and her experience that the POI will be no less than 2.5 metres before the AOI.
Forensic Officer Dale Woodland of the CRMIU conducted a mechanical investigation of Mr Bennett’s car, during which he observed minor impact damage to the front passenger side.
The examination did not reveal any faults or failures associated with Mr Bennett’s car that would have caused or contributed to the collision.22
Police examined Mr Bennett’s mobile phone and the call records do not disclose any use of the phone at the time of the collision. They do disclose that Mr Bennett received a text message at approximately 2.44pm, which I am satisfied was after the collision had occurred as it is five minutes after emergency services were contacted.
Police also obtained an extract of Mr Bennett’s driving offences, which revealed that his most recent offence occurred in June 2020 and his driver licence was suspended between 12 July 2020 and 12 October 2020 for exceeding the speed limit.23
Police did not formally interview Mr Bennett and ultimately did not charge him with any offence in connection with Mr Gorr’s death.
Expert evidence of Dr George Rechnitzer
Ms Gorr obtained an expert report dated 28 August 2023 from Accident Investigation and Collision Reconstruction expert, Dr George Rechnitzer.
Dr Rechnitzer largely agreed with the views of Dr Hardiman.24 In particular, he agreed that Mr Gorr’s bicycle was hit from the rear by Mr Bennett’s vehicle, when both vehicles were travelling linearly on Tooram Road at the northern edge of its intersection with Maria Street. Further, he 21 Statement of Detective Sergeant Dr Jenelle Hardiman dated 14 March 2023.
22 Statement of Dale Woodland dated 31 October 2021.
23 CB246, Extract of Road Safety Act offences for William Bennett.
24 Statement of Detective Sergeant Dr Jenelle Hardiman prepared 10 October 2023.
considered that the physical collision evidence is not sufficient to distinguish whether pre-impact, the bicycle had travelled straight on Tooram Road (from an earlier turn out of Sophia Street) or turned left from Maria Street into Tooram Road. He noted that this determination may depend on the veracity of the witness evidence.
Evidence was given at the inquest by the following witnesses: a) William David Bennett; and b) Detective Sergeant Dr Jenelle Hardiman.
Since preparing his report, Dr Rechnitzer has become gravely ill and was unable to attend Court to give evidence.
Mr Bennett
when he heard “a massive thud, just as I was at Maria Street” and he saw a “black blur” on the “left hand front corner” of his vehicle. He stated that he “had no idea what had happened.”26
Mr Bennett stated that he had not been distracted while driving prior to the collision. He also stated that he was familiar with the relevant section of Tooram Road as he drove along it every day. He stated that it was “impossible” that Mr Gorr had been travelling north along Tooram Road before Maria Street as he was keeping a proper lookout and would have seen him.27
When asked for an explanation as to why he did not see Mr Gorr come out of Maria Street prior to the collision, Mr Bennett stated that he was prevented from seeing any traffic emerging from that street by a fence that was erected on the south side of the intersection.
Dr Hardiman
She confirmed that there were a limited number of conclusions that could be definitively drawn from the evidence. Those conclusions were that Mr Bennett was travelling at around 48 to 50 kilometres per hour at the time of the collision; that Mr Gorr was hit from behind by the front left hand side of Mr Bennett’s vehicle, when both vehicles were travelling linearly on Tooram Road at the northern edge of its intersection with Maria Street; and Mr Gorr’s bicycle had been run over by Mr Bennett’s vehicle.
Dr Hardiman confirmed that the evidence did not enable her to conclusively determine whether Mr Gorr entered Tooram Road from Maria Street, or further south from Sophia Street. However, she maintained her view that it was more likely that he had entered from south of Maria Street.
Dr Hardiman agreed with Dr Rechnitzer’s calculations which he had used in his line-of-sight and PRT analysis. However, she stated that the lack of evidence in relation to the speed and direction of travel of Mr Gorr’s bicycle prior to the collision limited the utility of the exercise.
Notwithstanding, she did consider that if Mr Gorr had entered Tooram Road from Maria Street, he would have been capable of being seen by Mr Bennett as he approached the intersection.
Conclusions on expert evidence
I accept the evidence of Dr Hardiman and also the evidence of Dr Rechnitzer insofar as he agreed with Dr Hardiman.
I consider that Dr Rechnitzer’s line-of-sight and PRT analysis is of limited assistance in determining the circumstances surrounding the collision. I accept the evidence of Dr Hardiman that it is predicated on a serious of variables which are not able to be determined.28 Further, in my view, the analysis assumes that Mr Bennett would commence to take responsive action as soon as Mr Gorr was capable of being seen approaching Tooram Road from Maria Street, on the assumption that Mr Gorr would fail to give way at the intersection. I do not consider this to be a reasonable proposition.
Had Mr Gorr turned into Tooram Road from Maria Street, I am satisfied that he would have been capable of being seen by Mr Bennett as his vehicle approached the intersection. After reviewing the photographs of the scene, the report of Dr Rechnitzer and the evidence of Dr Hardiman,29 I am satisfied that Mr Bennett’s line of sight was obscured for a time by the fence on the southern side of Maria Street, but the obstruction would not have prevented him from being able to see Mr Gorr as he approached the intersection and before the collision.
I do not accept Mr Bennett’s evidence that the fence would have prevented him from seeing Mr Gorr entering Tooram Road from Maria Street before the collision. However, even if Mr Bennett had seen Mr Gorr prior to the collision, on the assumption that he came out of Maria Street, I am not satisfied that Mr Bennett would have had sufficient time to avoid it once Mr Gorr had passed over the give way markings at the intersection.
Submissions
Counsel Assisting and counsel for Ms Gorr submitted that the evidence does not enable a positive finding to be made in relation the route that Mr Gorr took to get to Tooram Road.
Counsel for Mr Bennett submitted that the evidence supported a finding that Mr Gorr entered Tooram Road from Maria Street and failed to give way to Mr Bennett’s vehicle.
I am satisfied that Mr Bennett was travelling at between 48 to 50 kilometres per hour on Tooram Road when he collided with Mr Gorr and his bicycle. Mr Gorr’s bicycle was hit from behind by Mr Bennett’s vehicle, when both vehicles were travelling linearly on Tooram Road at the northern edge of its intersection with Maria Street.
The expert evidence of Dr Hardiman from her review of the evidence is that it is more likely that Mr Gorr was travelling straight on Tooram Road rather than having turned from Maria Street, although it is not unlikely that he did turn from Maria Street. Ultimately, both she and Dr Rechnitzer determined that it could not be concluded exactly what path Mr Gorr took to get to Tooram Road.
The only witness to the collision is Mr Bennett and he has stated that Tooram Road was clear of traffic before his vehicle hit Mr Gorr’s bicycle. However, his evidence does not enable me to obtain a clear understanding of Mr Gorr’s movements prior to the collision. In particular, Mr Bennett did not see Mr Gorr at all prior to the collision and did not see him enter Tooram Road from Maria Street. Further, he was unable to provide a satisfactory explanation as to why he may not have seen Mr Gorr as his vehicle approached Maria Street prior to the collision.
Ultimately, Mr Bennett’s evidence is not of sufficient cogency for me to rely upon as the sole source of evidence to determine Mr Gorr’s movements before the collision.
It follows that I am unable to determine the route that Mr Gorr rode on his bicycle immediately before he was struck by Mr Bennett’s vehicle on 28 September 2021. In particular, the evidence does not enable me to determine with a comfortable level of satisfaction whether Mr Gorr turned into Tooram Road from Maria Street or whether he entered Tooram Road from further south.
It also follows that the evidence does not support a finding that Mr Gorr failed to give way at the intersection of Maria Street and Tooram Road. It is acknowledged that this finding which I made on the evidence before me on 22 May 2022 has been the cause of significant distress to Mr Gorr’s family.
Counsel for Ms Gorr submitted that the evidence warranted a notification to the Director of the Public Prosecutions pursuant to section 49(2) of the Act. I am not satisfied in the circumstances that such a notification is appropriate.
I confirm the following findings made on 22 May 2022 pursuant to section 67(1) of the Act: a) the identity of the deceased was Jon Gorr, born 3 June 1959; b) the death occurred on 28 September 2021 at Tooram Road, Allansford, Victoria, from head, chest and pelvic injuries, sustained in a cycle versus car motor vehicle incident; and c) further, I find that Mr Gorr’s death occurred in the circumstances described above.
Mr Gorr’s death has devastated his family and caused them immeasurable grief. I also acknowledge that Mr Bennett experienced trauma and distress from the incident and it significantly affected the first responders who attended the scene.
I convey my sincere condolences to Mr Gorr’s family for their loss.
Pursuant to section 73(1) of the Act, I order that this finding be published on the Coroners Court of Victoria website in accordance with the rules.
Signature: ______________________________________ Coroner David Ryan Date: 17 November 2023 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 inquest. 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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