Finding into death of Milan Rajic

IN THE CORONERS COURT COR 2023 006502 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner Simon McGregor Deceased: Milan Rajic Date of birth: 26 August 1983 Date of death: 23 November 2023 Cause of death: 1a: Traumatic head injury sustained in an e-bike incident Place of death: The Alfred Hospital 55 Commercial Road Melbourne Victoria 3004 Keywords: E-bike, helmet, traumatic brain injury

INTRODUCTION

1. On 23 November 2023, Milan Rajic was 40 years old when he died at The Alfred Hospital from injuries sustained in an unwitnessed fall off an electric bicycle (‘e-bike’). At the time of his death, Milan lived at 7 Rathmines Street, Officer, Victoria with his wife Carly and their three children.

2. Milan was a glazier by trade, physically active in his spare time, and enjoyed martial arts training and basketball.1

3. His medical history included congenital heart disease which was treated with placement of stents as a child. Milan attended regular checkups with a cardiologist as a result and underwent surgery to repair narrowing of his aorta when he was around 30 years old.2 Approximately 15 years ago, Milan had a fall in which he hit his head. Three days after the fall, he had a seizure and collapsed in the shower. He was taken to hospital by ambulance, where clinical staff determined that a concussion was causing the seizures, and also found a colloid cyst in his frontal lobe. He underwent surgery approximately 6 months later and aside from being ‘a bit forgetful’, he made a full recovery.3

THE CORONIAL INVESTIGATION

4. Milan’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.

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. 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 1 Statement of Carly Rajic, Coronial Brief.

2 See also Medical Deposition of Dr Arshia Azizeddin, Coronial Brief.

3 Statement of Carly Rajic, Coronial Brief.

comments or recommendations in appropriate cases about any matter connected to the death under investigation.

7. Victoria Police assigned an officer to be the Coronial Investigator for the investigation of Milan’s death. The Coronial 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.

8. This finding draws on the totality of the coronial investigation into the death of Milan Rajic 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.4

9. In considering the issues associated with this finding, I have been mindful of Milan’s human rights to dignity and wellbeing, as espoused in the Charter of Human Rights and Responsibilities Act 2006, in particular sections 8, 9 and 10.

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

10. On Saturday 4 November 2023, Milan and his family travelled from their home in Officer to Carly’s parents’ home at 51 Laurette Avenue, San Remo, for a Melbourne Cup long weekend visit. On Sunday 5 November 2023, they travelled from San Remo to visit friends in nearby Phillip Island. Milan had one beer with lunch. The family then returned to Laurette Avenue for an evening barbecue.5

11. At about 9:00 pm, after they had settled the children, Milan, Carly and some other friends walked to a pub in San Remo. Milan had two beers of unknown size and strength across a period of approximately one and a half hours. At 10:25 pm, the group left the pub, walking 4 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.

5 Statement of Carly Rajic, Coronial Brief.

past the nearby United service station at approximately 10:34 pm on their 1.2 km journey home.6

12. Sometime between 10.45 pm and 11:00 pm, Milan headed back to the service station on his father-in-law’s Aldi e-bike to buy cigarettes and soft drinks, but CCTV footage from the service station indicates he never arrived.7

13. He returned to the house about 10 minutes later and said words to Carly to the effect of, ‘I’ve stacked hard’. Carly noticed blood and abrasions to his head, and swelling prominent enough to look like an egg under his bald scalp. He was wearing a baseball cap, not a helmet. He started acting strangely and having seizure-like symptoms shortly after, so Carly called 000 and an ambulance was dispatched while she followed the call-taker’s first aid instructions.8

14. Despite my investigators’ extensive enquiries, there were no witnesses or CCTV footage capturing the incident, or even indicating its approximate location.9 Milan had, however, ridden this e-bike a number of times before, mainly on similar errands, and still had a current motorcycle licence, though he did not ride frequently. Carly described him as a safe rider who was not a risk-taker.10

15. On arrival of the paramedics, Milan was agitated and in an altered conscious state, with a significant haematoma on his head. Paramedics witnessed a Tonic-Clonic seizure lasting approximately 1 minute. He was sedated, intubated and evacuated by helicopter ambulance with a suspected traumatic brain injury.11

16. The initial CT scan at The Alfred Hospital in the early hours of 6 November 2023 confirmed multiple cranial fractures and bleeding. Drainage was attempted multiple times, but Milan’s condition continued to deteriorate over the following weeks and his injuries were determined to be non-survivable. Following a family meeting, a decision was made to transition Milan to comfort care, and he passed away on 23 November 2023 at 4:26 pm.12 6 Statement of Carly Rajic and summary of LSC Scott St Clair, Coronial Brief.

7 Statements of Carly Rajic and LSC Scott St Clair, Coronial Brief.

8 Statement of Carly Rajic, Coronial Brief.

9 Statement of LSC Scott St Clair, Coronial Brief.

10 Statement of Carly Rajic, Coronial Brief.

11 Statements of Mitchell Gibson and Bradley Hogan, Coronial Brief.

12 Medical Deposition of Dr Arshia Azizeddin, Coronial Brief. See also Alfred Health medical records.

17. My investigators subsequently inspected the e-bike in question and found it to be in good general condition, with functional lights and brakes, and no signs of any collisions with another vehicle. The front and rear wheel guards were slightly off centre, but this was likely to be a result of the fall rather than any third-party collision.13 It was about two years old and was ridden without incident in the days following Milan’s fall.14

18. The weather had been mild and clear that night, and did not present a distinct hazard, aside from the partial darkness that was the side effect of the local street lighting.15 Identity of the deceased

19. On 21 November 2023, Milan Rajic, born 26 August 1983, was visually identified by his wife, Carly Rajic.

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

Medical cause of death

21. Forensic Pathologist Dr Judith Fronczek from the Victorian Institute of Forensic Medicine conducted an external examination on 24 November 2023 and provided a written report of her findings dated 28 November 2023.

22. A post-mortem CT scan showed skull fractures, accompanied by both bleeding and swelling within the brain.

23. The findings upon the external examination of the body were consistent with the history given, and no other independently causative conditions or disease processes were detected.

24. Toxicological analysis of post-mortem blood samples identified the presence of therapeutic doses of drugs associated with the emergency stabilisation and medical care,16 but did not identify the presence of alcohol or any other common drugs or poisons.

13 Statement of LSC Scott St Clair, Coronial Brief.

14 Statements of Carly Rajic and LSC Scott St Clair, Coronial Brief.

15 Statement of LSC Scott St Clair, and Appendix 1 San Remo Weather Print Out, Coronial Brief.

16 Fentanyl (analgesia administered by ambulance members), Levetiracetam (Levetiracetam is an antiepileptic used for the control of partial onset seizures), Midazolam (Midazolam is an imidazobenzodiazepine derivative used as a preoperative medication, antiepileptic, sedative-hypnotic, and anaesthetic induction agent) and its metabolite, Laudanosine.

25. Dr Fronczek provided an opinion that the medical cause of death was 1(a) traumatic head injury sustained in an e-bike incident, and I accept her opinion.

FINDINGS AND CONCLUSION

26. The standard of proof for coronial findings of fact is the civil standard of proof on the balance of probabilities, with the Briginshaw gloss or explications.17 The effect of the authorities is that adverse comments or findings should not be made unless the evidence provides a comfortable level of satisfaction that an individual (or institution) caused or contributed to the death, and in the case of individuals acting in a professional capacity, that they departed materially from the standards of their profession.

27. Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings: a) the identity of the deceased was Milan Rajic, born 26 August 1983; b) the death occurred on 23 November 2023 at The Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, from 1(a) traumatic head injury sustained in an e-bike incident; and c) the death occurred in the circumstances described above.

28. Having considered all of the available evidence, I am satisfied that Milan knowingly rode the bicycle without a helmet. No other circumstances of his actual fall can be established to the requisite standard of proof.

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

Pursuant to section 73(1A) of the Act, I order that this finding be published on the Coroners Court of Victoria website in accordance with the rules.

17 Briginshaw v Briginshaw (1938) 60 CLR 336 at 362-363: ‘The seriousness of an allegation made, the inherent unlikelihood of an occurrence of a given description, or the gravity of the consequences flowing from a particular finding, are considerations which must affect the answer to the question whether the issues had been proved to the reasonable satisfaction of the tribunal. In such matters “reasonable satisfaction” should not be produced by inexact proofs, indefinite testimony, or indirect inferences…’.

I direct that a copy of this finding be provided to the following: Carly Rajic, Senior Next of Kin Ashlee Washington, Alfred Health Leading Senior Constable Scott St Clair, Coronial Investigator Signature: ___________________________________ Coroner Simon McGregor Date: 22 January 2025 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.