Finding into death of Ryleigh James Pallot

IN THE CORONERS COURT COR 2021 007031 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner Catherine Fitzgerald Deceased: Ryleigh James Pallot Date of birth: 21 November 1993 Date of death: 31 December 2021 Cause of death: 1(a) Chest injuries following a cliff collapse Place of death: Jarosite Headland on Addiscott Beach, Bells Beach, Victoria, 3228

INTRODUCTION

1. On 31 December 2021, Ryleigh James Pallot was 28 years old when he died following a cliff collapse. At the time of his death, Mr Pallot lived at Surrey Hills, Victoria with housemates.

THE CORONIAL INVESTIGATION

2. Mr Pallot’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.

3. The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death, and the circumstances in which the death occurred. The 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.

4. 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.

5. Victoria Police assigned an officer to be the Coroner’s Investigator for the investigation of Mr Pallot’s death. The Coroner’s Investigator conducted inquiries on my behalf and submitted a coronial brief of evidence.

6. This finding draws on the totality of the coronial investigation into the death of Ryleigh James Pallot 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.1 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.

MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Circumstances in which the death occurred

7. At about 1.00pm on 31 December 2021, Ryleigh Pallot attended Southside Beach, which is located near Bells Beach in south-west Victoria. He drove there with his girlfriend, Ashleigh Hoskin, and two friends, Roman Maksymyschyn and Michael Ratcliffe, and parked at the Southside Beach Carpark. From there, the group walked down to Southside Beach, which was only a few minutes from the carpark.

8. Once at Southside Beach, the group met up with two other friends, James Goodear and Steph Shepherd. The group of six friends then walked about one kilometre in a westerly direction to Addiscot Beach. It was a hot day, so the group set up a picnic blanket, towels, and esky in the shade under the Jarosite Headland cliffs.

9. At about 2.10pm, Mr Goodear and Ms Shepherd were swimming in the water, with the remainder of the group sitting together under the cliffs. The group heard a “loud crack (like lightning strike)” and rocks fell from the cliff face and covered the group on the ground.

Ms Hoskin, Mr Maksymyschyn and Mr Ratcliffe were all hit by falling debris but were able to stand up. They observed Mr Pallot was covered by rocks and debris and was not moving.

10. Ms Hoskin and Mr Maksymyschyn ran over to Mr Pallot and noted that his “eyes were black and he looked disorientated”. The pair used a deflated banana lounge as a stretcher to carefully move Mr Pallot away from the cliff face in case there were further collapses. Another beachgoer brought over their beach shelter, to create shade for Mr Pallot. Mr Ratcliffe and other bystanders called 000 to request assistance.

11. Mr Maksymyschyn, Ms Hoskin, and other bystanders comforted Mr Pallot. One of the bystanders was a nurse, so she assisted Mr Pallot and moved him into the recovery position, while his friends reassured him and tried to keep him calm.

12. A 000-call was made by Mr Ratcliffe and answered by Telstra at 2.12.23pm and was answered by an Emergency Services Telecommunications Authority (ESTA) ambulance call-taker (ACT) at 2.14.42pm. The event type was created as “30B1-AP Traumatic Injuries, possibly dangerous body area” which automatically assigned a Priority 3 response. The ACT referred the matter to an Ambulance Victoria (AV) Clinician, who subsequently upgraded the priority to Priority 1 at 2.20.19pm.

13. General purpose ambulance unit ANGA7418 and Mobile Intensive Care Ambulance (MICA) unit Z230 were dispatched to the event at 2.20.29pm and 2.20.31pm, respectively. Another general purpose ambulance unit TQAY7596 was dispatched at 2.21.33pm.

14. Due to the difficult terrain, Air Ambulance Victoria (AAV) and the Helicopter Emergency Medical Service (HEMS) were dispatched at 2.23.13pm and 2.25.03pm respectively. Two Victoria Police units were dispatched at 2.26.53pm, followed by the Victoria State Emergency Services unit TORQ at 2.27.15pm.

15. The first Victoria Police unit arrived on scene at 2.41pm, followed by TQAY7596 at 2.43pm.

Due to the remote location of the incident, paramedics and police could not reach Mr Pallot until 3.01pm.

16. On their initial assessment of Mr Pallot, paramedics found that he had significant lower limb injuries, possible pelvic injuries and he was short of breath. Paramedics administered intravenous pain relief and attempted to stabilise him for air transport to hospital. The HEMS crew commenced moving Mr Pallot to the helicopter. During transport to the helicopter, he experienced a cardiac arrest. Despite the best efforts of all emergency personnel involved, Mr Pallot could not be revived, and resuscitation efforts ceased at 4.20pm.

Identity of the deceased

17. On 5 January 2022, Ryleigh James Pallot, born 21 November 1993, was visually identified by his girlfriend, Ashleigh Hoskin.

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

Medical cause of death

19. Senior Forensic Pathologist Dr Michael Burke, from the Victorian Institute of Forensic Medicine (VIFM), conducted an examination on 3 January 2022 and provided a written report of his findings dated 10 January 2022.

20. The post-mortem examination revealed findings consistent with the reported history.

21. The post-mortem CT scan showed a left haemothorax, bilateral pneumothoraces, fractured ribs (lateral) on the left, posterior dislocation of right hip, with no head injuries.

22. Toxicological analysis of post-mortem samples identified the presence of ondansetron2, ketamine3 and lignocaine4 (administered by paramedics) but did not identify the presence of alcohol or any other commonly encountered drugs or poisons.

23. Dr Burke provided an opinion that the medical cause of death was “1(a) Chest injuries following a cliff collapse”.

24. I accept Dr Burke’s opinion.

FURTHER INVESTIGATIONS

25. As part of my investigation, I referred this matter to the Coroner’s Prevention Unit (CPU)5 to research whether other fatalities have occurred following a cliff collapse. Enquiries with the CPU suggest there have not been any other similar fatalities in Victoria.

26. I also requested statements from several agencies involved in this incident and in the management of the cliffs and beach, in response to issues which were considered as part of the investigation. These are summarised below.

Signage present at Southside and Addiscot Beach prior to the incident

27. In her statement to the Court, Ms Hoskin said “there was no visible signage to warn people that it was a potentially dangerous area in regards to the cliffs”. Similarly, Mr Goodear stated “There were no signs erected at the Southside beach carpark, on the footpath to the beach or at the base of the cliffs to indicate it was a dangerous area”.

28. The Coroner’s Investigator, Leading Senior Constable (LSC) Shayne McTigue, provided photographs of the signage present at Southside and Addiscot Beaches at the time of the incident. At the top of the path leading to Southside Beach, there was a sign which indicated “Unstable Cliffs Keep Clear”. A similar sign was posted at the top of the stairs leading to Addiscot Beach. The sign also listed several other risks being “Submerged objects” and 2 Ondansetron is an indole derivative that has serotonin 5-HT3 receptor blocking activity. It is indicated for postoperative nausea and vomiting from cancer chemotherapy.

3 Ketamine is an anaesthetic normally used for short and medium duration operations as an induction agent.

4 Lignocaine (lidocaine) is an amide local anaesthetic and antiarrhythmic drug.

5 The Coroners Prevention Unit (CPU) was established in 2008 to strengthen the prevention role of the coroner. The unit 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. The CPU is comprised of health professionals with training in a range of areas including medicine, nursing, public health and mental health.

“Strong currents”. Several smaller signs were posted in the sand at Addiscot Beach, which also warned of unstable cliffs.

29. While it is apparent that there were signs warning visitors about the unstable cliffs at Southside and Addiscot beaches at the time of the incident, they were missed by Mr Pallot and his friends.

ESTA and Ambulance Victoria response

30. Due to the location and the injuries suffered by Mr Pallot, the emergency services response was complex and challenging for all involved. AV paramedics were hampered by the terrain and remote location of Mr Pallot and his friends. I am satisfied that their treatment and response was appropriate in very challenging circumstances.

31. Enquiries were made with ESTA who provided a response indicating that the management of the emergency call was appropriate. I do note that there was a delay of 2 minutes and 19 seconds connecting from the Telstra call-taker to the ESTA ACT, however, having regard to the severity of the injuries and the complexity of the emergency response at this location, there is no indication that this small delay adversely impacted the outcome in this case.

Cliff collapse monitoring by Parks Victoria prior to the incident

32. Cliffs in the Great Ocean Road area are managed by both Parks Victoria and the Great Ocean Road Coast and Parks Authority (GORCPA). Addiscot Beach and the Jarosite Headlands cliff was managed by Parks Victoria at the time of the incident. Despite not being the responsible agency, GORCPA stated that they work closely with Parks Victoria to ensure consistency in managing beach safety along the Surf Coast.

33. Parks Victoria and GORCPA undertake regular geotechnical assessments of the cliffs within their respective management areas. At the time, an Operational Management Plan was in place, which guided Parks Victoria’s assessment and management of the area.

Parks Victoria response

34. Following Mr Pallot’s death, Parks Victoria engaged Golder Associates (Golder) to undertake an emergency assessment of the cliff face at Addiscot Beach. Golder attended the scene at Addiscot Beach on 1 January 2022 and noted that the cliff collapse occurred on a hot day (35 degrees Celsius), following nearly two weeks of dry weather, which was preceded by a relatively wet period. The Golder review opined that the rockfall was triggered by the

expansion and contraction of the weak rock, caused by a cycle of wetting and drying. The Golder review stated that this is a “relatively rare trigger mechanism in Victoria with experience indicating most rockfalls are triggered by extreme or prolonged rainfall”.

35. The Golder review explained that rockfalls and landslides appear to be a natural and ongoing occurrence at Addiscot Beach, and it is therefore not practical or possible to prevent them.

Parks Victoria noted another significant collapse occurred nearby on 2 February 2022 and a smaller collapse occurred on 18 February 2022.

36. In the immediate aftermath of the incident of 31 December 2021, the Golder review recommended the following short-term risk mitigation strategies: a) Immediate restriction of access to an area within 10 metres of the base of the cliff; b) Prevention of beachgoers setting up tents or towels or otherwise lingering in the area from 10 to 30 metres from the base of the cliff, and; c) Raise public awareness with high profile signage, ranger patrols during busy periods, alerts published online.

37. Parks Victoria actioned the above suggestions, with alerts now published on the Great Otway National Park website. Media releases and targeted communications have also been issued.

Ranger patrols were increased during January 2022 to increase awareness and reduce noncompliance and signage was erected to denote exclusion and “no stationary” zones.

38. The signage at Addiscot Beach has been changed and now depicts the words “DANGER” in capital letters and explains to visitors that cliffs are prone to sudden and unpredictable collapses and that visitors must not enter exclusion zones. Parks Victoria explained that it is often difficult to erect signage on beaches and in coastal areas as these signs are subject to tides. In this case, consideration was given to erecting signs on Addiscot Beach itself, however the “coastal processes are too strong within the area to allow anything to be adequately installed”. Therefore, new signs have been erected along both access paths that lead to Addiscot Beach, which all visitors must pass by to access the beach.

39. The Golder review also recommended the following medium to long-term risk mitigation strategies: a) Establish a rockfall and landslide policy, similar to that of the New South Wales (NSW) Parks and Wildlife Service;

b) Establish procedures for assessing landslide and rockfall risks on the Victorian coastline and implementing those procedures, similar to the approach taken by the NSW Roads and Maritime Service; and c) Implement risk mitigation commensurate with the level of risk, i.e., engineered measures such as rockfall barriers at very high-risk locations.

40. Parks Victoria stated to the Court that they do not currently have aa specific rockfall and landslide management policy. At present, management is guided by the Anglesea Geotechnical Risk Assessment Operational Management Plan 2016, and this was also the case at the time of the incident. Parks Victoria stated that there have been initial discussions with the (then-named) Department of Environment, Water, Land and Planning (DELWP) to establish a state-wide rockfall and landslide policy.

41. Both GORCPA and the Golder review have suggested that a state-wide rockfall and landslide management and assessment policy akin to that in NSW would be beneficial, and I have made recommendations accordingly.

FINDINGS AND CONCLUSION

42. Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings: a) the identity of the deceased was Ryleigh James Pallot, born 21 November 1993; b) the death occurred on 31 December 2021 at Jarosite Headland on Addiscott Beach, Bells Beach, Victoria, 3228, from chest injuries following a cliff collapse; and c) the death occurred in the circumstances described above.

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

(i) I recommend that the Department of Energy, Environment and Climate Action (DEECA), Parks Victoria and GORCPA consider developing and implementing a state-wide rockfall and landslide assessment and management policy, which includes consideration of implementing risk mitigation commensurate with the level of risk.

(ii) I recommend that Parks Victoria consider amending the new signage at Addiscot Beach to state that a cliff collapse has led to injury and death to reinforce the danger posed to visitors from cliff collapse.

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

I direct that a copy of this finding be provided to the following: John and Kerri Pallot, Senior Next of Kin Ambulance Victoria Department of Energy, Environment and Climate Action Emergency Services Telecommunications Authority (C/- K&L Gates) Great Ocean Road Coast and Parks Authority Parks Victoria Leading Senior Constable Shayne McTigue (VP30139), Victoria Police, Coroner’s Investigator Signature: ___________________________________ Coroner Catherine Fitzgerald Date : 17 June 2024 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.