Finding into death of Pauline Elizabeth Bower

IN THE CORONERS COURT COR 2023 006644 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner David Ryan Deceased: Pauline Elizabeth Bower Date of birth: 4 June 1946 Date of death: 29 November 2023 Cause of death: Multiple injuries sustained in a motor vehicle incident Place of death: Princes Highway Club Terrace, Victoria Keywords: Motor vehicle collision – wet conditions – road surface - traction

INTRODUCTION

1. On 29 November 2023, Pauline Elizabeth Bower was 77 years old when she died from injuries she sustained in a motor vehicle incident. At the time of her death, Pauline lived with her husband, Terry Bower, in Paynesville, Victoria. She is also survived by her children, Sophie Walton and Alecia O’Toole.

THE CORONIAL INVESTIGATION

2. Pauline’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 coronial investigation was paused while a related criminal investigation was completed.

3. 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.

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 Coronial Investigator for the investigation of Pauline’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.

6. This finding draws on the totality of the coronial investigation into Pauline’s death including evidence contained in the coronial brief. While 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. In the afternoon on 29 November 2023, Terry and Pauline were returning to Paynesville after visiting their daughters and their families in Canberra. Terry was driving their 2010 Renault Master campervan and Pauline was sitting in the front passenger seat.

8. At around 2.20pm, Terry and Pauline were driving southwest along the Princes Highway in Club Terrace in eastern Victoria and had just entered a left-hand bend. The relevant section of road consists of a bitumen dual carriage way with a single lane of traffic in either direction divided by solid double white lines. The speed limit is 100 kilometres per hour. It was raining and the road was wet although visibility was good.

9. At the same time, Trevor Jones was driving his 2006 Toyota Landcruiser in the opposite direction along the Princes Highway on his way to Bermagui to visit his parents. He had just entered a right-hand bend and passed a sign warning of the bend and providing for an advisory speed of 80 kilometres per hour.

10. As the two cars approached each other, Terry recalled that the Landcruiser suddenly lost control and rotated across the road and into the path of the Renault. Terry was unable to avoid a collision and the passenger side of the Landcruiser impacted the front of the Renault. Both vehicles came to rest after the collision and suffered significant damage. The damage to the Renault was particularly concentrated towards the front passenger side. The occupants of both vehicles had been wearing seatbelts and airbags in both vehicles had deployed.

11. Passing motorists stopped at the scene to provide assistance and emergency services were contacted. A registered nurse who had been working nearby was the first to arrive at the scene in response to the call. He arrived at around 2.45pm and assessed Pauline and found her to be deceased. Ambulance Victoria, the Country Fire Authority, the State Emergency Service and Victoria Police arrived at the scene shortly afterwards. Terry had to be extracted from the Renault. He sustained serious injuries and was transported to the Alfred Hospital for emergency treatment.

12. Trevor was able to extract himself from the Landcruiser. He told police at the scene that he had no memory of the incident but he did recall that he had been driving to Bermagui to visit his parents and that he was familiar with the road. He appeared to be uninjured but was transported to Bairnsdale Hospital for observation.

POLICE INVESTIGATION

13. The Major Collision Unit and the Collision Reconstruction Unit of Victoria Police attended the scene.

14. Blood samples were taken from both Terry and Trevor and subsequent testing returned negative results for drugs and alcohol. They also both held current Victorian driver licences.

There is no evidence that Trevor had been distracted at the time of the collision or had been using his mobile phone.

15. The Landcruiser was mechanically inspected by Victoria Police and the examination did not reveal any faults, failures or conditions that could have caused or contributed to the collision.

16. A reconstruction expert from Victoria Police examined the scene and provided the following opinion in relation to the circumstances of the collision: In my opinion, the Toyota Landcruiser had been travelling in a northeasterly direction along Princes Highway, Club Terrace. At this same time the Renault Master had been travelling in a southwesterly direction along Princes Highway, approaching from the opposite direction.

As the Toyota commenced to negotiate a right-hand curve, the Toyota began to rotate clockwise and veered into the opposite lane and into the path of the Renault. This resulted in the front of the Renault impacting the passenger side of the Toyota… It is not possible to determine the impact speed of either vehicle. However, in my opinion, the evidence at the scene does not indicate either of the vehicles had been travelling at excessive speeds.

Without the presence of any pre-impact evidence from either vehicle, it is not possible to assert the reason/s as to why this collision occurred. It is known at the time of this collision weather conditions were such that it was raining, at times heavily, and the road was wet.

Without the results that a scrim test2 may have provided, it is not possible to determine the drag factor of the road surface. Therefore it is not possible to rule out that the Toyota lost traction on the wet road, leading to the driver losing control of the Toyota.

2 A scrim test, or a skid resistance test, is a method of testing the skid resistance of a paved surface using a Scrim Machine.

Test results do not provide a clear black and white indicator to the safety of a road surface, but are a useful tool. On 5 December 2023, Victoria Police requested that VicRoads conduct a scrim test on the road at the site of the collision.

17. On 11 December 2024, Trevor was formally interviewed by Victoria Police and he exercised his right to provide “no comment” in response questions relating to the circumstances of the collision. Police prepared a brief of evidence in support of criminal charges against Trevor, but after obtaining advice from the Director of Public Prosecutions, no criminal proceedings were commenced.

18. Victoria Police conducted a search of their Traffic Incident System which disclosed that a number of similar collisions (loss of traction in wet conditions) had occurred on the Princes Highway in Club Terrace.

19. Scrim testing was conducted by the Department of Transport on the road surface on the northeast bound section of the Princes Highway in the area of the collision site. The testing disclosed that skid resistance fell below “investigatory levels”3 in at least one wheel path and in certain locations there was a high differential and some variability between the skid resistance available in the left and right wheel paths. The report concluded that “these observations do prompt a level of concern,,,, and suggest it would be beneficial to undertake further investigations into the safety and crash potential of this site”.

20. The Department of Transport has advised the Coronial Investigator that the following remedial action has been taken at the site of the collision: a) Temporary “Slippery When Wet” warning signs have been installed. Permanent signs are scheduled to be installed by August 2025; b) Temporary 80 kilometres per hour speed limit signs have been installed. Permanent signs are scheduled to be installed by August 2025; and c) The relevant section of road will be submitted for consideration under the 2026-2027 Black Spot Program, with a view to securing funding for further safety improvements.

Identity of the deceased

21. On 5 December 2023, Pauline Elizabeth Bower, born 4 June 1946, was visually identified by her son-in-law, David Timothy Walton.

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

3 Results at “investigatory levels” are an indication that further reasoned consideration of the site is required while “intervention levels” are an indication that mandatory action is required.

Medical cause of death

23. Forensic Pathologist Dr Brian Beer from the Victorian Institute of Forensic Medicine conducted an examination on 1 December 2023 and provided a written report of his findings dated 4 December 2023. Dr Beer noted extensive and serious injuries including head injuries and multiple fractures.

24. Toxicological analysis of post-mortem samples identified the presence of bisoprolol.4

25. Dr Beer provided an opinion that the medical cause of death was 1(a) Multiple injuries sustained in a motor vehicle incident.

26. I accept Dr Beer’s opinion.

FINDINGS AND CONCLUSION

27. Pursuant to section 67(1) of the Act, I make the following findings: a) the identity of the deceased was Pauline Elizabeth Bower, born 4 June 1946; b) the death occurred on 29 November 2023 at Princes Highway, Club Terrace, Victoria, from multiple injuries sustained in a motor vehicle incident; and c) the death occurred in the circumstances described above.

28. Having considered all of the circumstances, I am satisfied that Pauline’s death was the result of a tragic accident. I am not satisfied that either vehicle was speeding immediately before the collision and it is likely that the Landcruiser lost traction in the wet conditions and veered into the path of the Renault. I am satisfied that there was nothing Terry could have done to avoid the collision.

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

1. The Department of Transport and Planning undertake further investigations of the road surface on the Princes Highway in Club Terrace at the site of the collision and consider whether 4 Bisoprolol is a synthetic beta-blocker indicated for hypertension.

further safety interventions are required to reduce the risk of vehicles losing traction in wet conditions.

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

I direct that a copy of this finding be provided to the following: Terry Bower, Senior Next of Kin Department of Transport and Planning Detective Senior Constable Lauren McNiece, Coronial Investigator Signature: ___________________________________ Coroner David Ryan Date: 13 October 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.