Inquest into the Deaths of Ian Bradley Vincent and Kane Edwin Nelson

Coroners Act 1996 [Section 26(1)] Western Australia

RREECCOORRDD OOFF IINNVVEESSTTIIGGAATTIIOONN IINNTTOO DDEEAATTHH Ref: 27/14 I, Sarah Helen Linton, Coroner, having investigated the death of Ian Bradley VINCENT and the suspected death of Kane Edwin NELSON with an inquest held at the Perth Coroner’s Court, Court 51, CLC Building, 501 Hay Street, Perth, on 15 July 2014 find that:

1. the identity of the deceased person was Ian Bradley VINCENT and that death occurred on 8 December 2012 at Redgate Beach, Witchcliffe, as a result of immersion; and

2. the death of Kane Edwin NELSON has been established beyond all reasonable doubt and that the identity of the deceased person was Kane Edwin NELSON and that death occurred on 8 December 2012 in sea off Redgate Beach, Witchcliffe, as a result of immersion; in the following circumstances - Counsel Appearing: Sergeant L Housiaux assisting the Coroner.

Mr D Anderson (State Solicitor’s Office) appearing on behalf of the Department of Parks and Wildlife.

TABLE OF CONTENTS Inquest into the death of Ian Bradley VINCENT and the suspected death of Kane Edwin NELSON 1

INTRODUCTION

1. On 8 December 2012 three men went into the ocean off Redgate Beach in Witchcliffe, Western Australia. Only one of those men came out of the water alive. Of the others, one - Dr Ian Bradley Vincent (Dr Vincent) - was eventually pulled from the water in an unresponsive state. He could not be resuscitated despite the best efforts of his rescuers. The other man - Kane Edwin Nelson (Mr Nelson) - was last seen disappearing under the waves near Redgate Beach. His body has never been found, despite extensive search efforts.

2. Pursuant to s 19(1) of the Coroners Act 1996 (WA) a coroner has jurisdiction to investigate a death if it appears that the death is, or may be, a reportable death (as defined in s 3 of the Act). A death is defined in s 3 of the Act to include a “suspected death”.

3. Section 22(2) of the Act permits a coroner who has jurisdiction to investigate a death to hold an inquest if the coroner believes it is desirable.

4. The death of Dr Vincent was a reportable death and was reported to the State Coroner by police. The subsequent police investigation into the death of Dr Vincent identified evidence that also pointed towards the suspected death of Mr Nelson, in circumstances that would make it a reportable death under the Act.

On that basis, the State Coroner concluded it was desirable to hold an inquest into the suspected death of Mr Nelson, as well as the death of Dr Vincent, which occurred at the same time.

5. Accordingly, I held an inquest into the death of Dr Vincent and the suspected death of Mr Nelson at the Perth Coroner’s Court on 15 July 2014.

6. The inquest focused primarily on determining whether the death of Mr Nelson could be established to my satisfaction beyond reasonable doubt. In addition, evidence was heard about problems with the signage in Inquest into the death of Ian Bradley VINCENT and the suspected death of Kane Edwin NELSON 2

the area of Redgate Beach at the time of the incident and what steps have been taken to improve the signage since that time, as well as other features of Redgate Beach relevant to public safety issues.

7. The documentary evidence comprised a police investigation report by Sergeant Paul Daly, the Officer in Charge of the local police station at the time of the incident, with numerous attachments.1 In addition, reports were provided on behalf of Surf Life Saving Western Australia (SLSWA) and the Department of Parks and Wildlife (the Department).2 A few additional documents were also tendered during the inquest.3

8. Oral testimony was given by Sgt Daly, Mr David Bradley (the uncle of Dr Vincent and the surviving member of the group who went into the sea that day), the Community Safety Manager from SLSWA, Mr Christopher Peck, and the Visitor Risk Management Coordinator from the Department of Parks and Wildlife, Mr Michael Phillips.

9. The documentary evidence and the oral testimony formed the basis for the facts found below.

THE DECEASED Dr Vincent

10. Dr Vincent was born in Austin, Texas and was raised in in a loving family. As an adult he excelled as an ice hockey player and also developed an interest in human health, which led him to a medical career and eventually a residency in anaesthesiology. He had recently been accepted to a fellowship to the Los Angeles Children’s Hospital to specialise in paediatric anaesthesiology.

1 Exhibit 1.

2 Exhibit 2.

3 Exhibit 3 – Letter from State Solicitor’s Office dated 10.7.14; Exhibit 4 – 5 pages of photos of Signage; Exhibit 5 – Table of signage; Table 6 – Risk Symbol Index; Exhibit 7 – Submission from Christine Nelson.

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11. Dr Vincent was known by his family and friends to be a very fit and healthy 31 year old man who always had a positive attitude and an ability to cope well under pressure.

12. In November 2012 Dr Vincent travelled to Nepal to work as a volunteer with Save the Children, performing hand and foot surgery on children who could not afford surgical treatment. When Dr Vincent finished his work in Nepal he flew to Perth, Western Australia to visit his uncle, David Bradley. It was during this visit to Western Australia, while they were staying at a beach house in Yallingup to enjoy the Australian summer weather, that Dr Vincent sadly drowned.

Mr Nelson

13. Mr Nelson was a 22 year old man who was born and lived in Perth, Western Australia. He had also been raised in a loving home and maintained a close relationship with his relatives as an adult.

14. Mr Nelson had recently found an outlet for his creative energy in designing and creating jewellery, and he was enthusiastically making plans to study and work in jewellery design.

15. Mr Nelson was also in a committed relationship with his girlfriend, Heather Bradley, who is the daughter of Mr Bradley. Mr Nelson accompanied Ms Bradley and her relatives to Yallingup in December 2012, which is how he came to be at Redgate Beach that day and eventually went missing.

REDGATE BEACH

16. Redgate Beach is located within the Leeuwin-Naturaliste National Park, in the south-western corner of Western Australia.4 It falls within the shires of Busselton and 4 Exhibit 2, Tab 9, Department Report, 2.

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August-Margaret River but its management is the primary responsibility of the Department of Parks and Wildlife (the Department) on behalf of the Government of Western Australia.5

17. As at 1 July 2013 the total area of the Department’s managed lands and waters was 28,531,987 hectares,6 which is a vast area.

18. Many of the lands and waters managed by the Department have inherent dangers associated with them. The Department attempts to balance the demands for access to, and enjoyment of, these lands and waters, against the requirement for visitor safety.7 Redgate Beach is one such area with inherent risks that the Department attempts to manage in a reasonable and practical way.8

19. The beach itself is located on the southern side of Isaacs Rock. It is a 350 metre long, west-facing, relatively exposed beach. Waves average over 1.5 metres and maintain an 80 metre wide central bar, with two permanent rips draining out against the rocks to either end.

There is a right hand break into the northern rip, as well as beach breaks across the bar.9 The above depicts an aerial view of Redgate Beach which can be found in Exhibit 2, Tab 1 of the SLSWA Report at 5 Exhibit 2, Tab 9, Department Report, 1 - 2.

6 Exhibit 2, Tab 9, Department Report, 1.

7 Exhibit 2, Tab 9, Department Report, 1.

8 Exhibit 2, Tab 9, Department Report, 1.

9 Exhibit 2, Tab 1, SLSWA Report, 22.

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20. Redgate Beach has been assigned an ABSAMP (Australian Beach Safety & Management Program) average rating of 8 out of 10, which categorises the beach as highly hazardous.10 The rating is based on the morphology of the beach environment. Even when the water at the beach may appear benign and calm, the particular rips in that area and the volume of water mean that the beach is considered hazardous in all conditions. It is for this reason that Redgate Beach is one of the highest rated hazardous beaches in the State.11 When the swell and sea conditions increase, Mr Peck from SLSWA indicated that the rating would be expected to increase even further.12

21. According to Mr Peck, although the rip is always running at Redgate Beach, it is not always noticeable to people who are inexperienced, or not used to looking for them.13 The water may, therefore, appear deceptively safe when it is calm, even though it is objectively always dangerous.14

22. The Department has acknowledged the inherent dangers of the beach by placing risk signs at various points to alert visitors to the dangers it poses. Just before the incident that is the focus of this inquest the Department had five risk signs in place at the beach stating that it was a “Coast Risk Area”, with a large triangular “Danger” symbol underneath, accompanied by the following warnings relevant to this inquest:

• Dangerous rips can occur off this beach.

• Watch for freak waves and swell.15

23. Regrettably, on the evening prior to 8 December 2012 two of those signs had fallen prey to the vandalism that is prevalent in the Leeuwin-Naturaliste National Park region, due to the high number (and diverse range) of 10 Exhibit 2, Tab 1, SLSWA Report, 22 - 23.

11 T 37 (Peck, C.W.).

12 T 37 (Peck, C.W.).

13 T 37 (Peck, C.W.).

14 T 39 (Peck, C.W.).

15 Exhibit 2, Tab 4, Attachment 1, 8; Tab 9, Attachment 3, 1.

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visitors in the area.16 These signs were ordinarily situated at the entrance of the two main pathways to the beach.17

24. Later investigations found that a group of local youths had camped at the beach late on 7 December 2012 and two of the youths admitted that they had each destroyed one of the signs by pulling them out of the ground and later burning them on the campfire.18 They could provide no explanation for why they had done so.

Both were dealt with by referral to the Juvenile Justice Team.19

25. Apparently the group of youths were still camping at Redgate Beach on 8 December 2012 and witnessed the search for Dr Vincent and Mr Nelson. At least one boy from the group described himself as shocked over what had happened.20 It is to be hoped that witnessing the aftermath of the tragic events of that day will have taught those young people about the very grave consequences that may flow from senseless acts of vandalism and they will grow up to be adults who teach others the lesson they have learnt.

8 DECEMBER 2012

26. On 7 December 2012 Dr Vincent and Mr Nelson went to stay in Yallingup, Western Australia, with Mr Bradley, Ms Bradley and an American friend of Dr Vincent’s who was travelling with him, Dr Matthew Hotchkiss.21

27. The following morning they awoke to a beautiful summer’s day. The group walked to Yallingup beach and had a coffee. The photo below shows Dr Vincent and Mr Nelson in a light-hearted moment that morning.

16 Exhibit 2, Tab 9, Attachment 3, 1.

17 Exhibit 1, Tab 3, 5; Exhibit 2, Tab 4, Attachment 3.

18 Exhibit 1, Tab 3, 6; Tab 19.

19 T 13 – 14 (Daly, P.M. (Sgt)); Exhibit 1, Tab 3, 6 – 7.

20 Exhibit 1, Tab 19 [34] – [38].

21 T 18 (Bradley, D.M.).

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The above photograph depicts Dr Vincent and Mr Nelson as can be found in Exhibit 1, Tab 4, Attachment to Sgt Daly’s Report

28. They returned to the house late morning and the two doctors went for a run before they all shared a late breakfast. After breakfast they discussed their plans for the rest of the day.22

29. Mr Bradley offered to drive them to Redgate Beach in Witchcliffe as he had been there previously on a hiking trip and considered it spectacularly beautiful, so he thought it would be a good place to show his American visitors. Ms Bradley suggested they could go there and have a picnic on the beach and teach their visitors how to play beach cricket, an Australian beach tradition.23

30. They left Yallingup and arrived at Redgate Beach at about 12.30pm.24 Mr Bradley had been to Redgate Beach previously and gone hiking on the rocks but he had not swum there before, and the group had no preconceived idea of going swimming there on that day.25

31. Mr Bradley did not recall having seen warning signs when he went there previously,26 and it is established 22 T 19 (Bradley, D.M.).

23 T 19 (Bradley, D.M.).

24 T 19 (Bradley, D.M.).

25 T 19 (Bradley, D.M.).

26 T 19 (Bradley, D.M.).

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above that on this particular day the signage on the two paths to the beach were missing. The members of Mr Bradley’s party were, therefore, unaware of the particular dangers presented for swimmers by the rips at Redgate Beach.

32. They walked down to the beach and did not walk far along the beach before stopping as they had a lot of things to carry.27 As Mr Peck from SLSWA pointed out at the hearing, the beach access track from the car park leads people to an entry location on the beach adjacent to where the northern rip is normally permanently located.28 Therefore, the group must have set up close to this point, which is reflected in where the incident eventually occurred, as identified in the photograph below.

The above photograph depicts the area where the incident occurred as described in Exhibit 2, Tab 1, p.12 of the SLSWA Report 27 Exhibit 1, Tab 12 [11].

28 T 29 (Peck, C.W.); Exhibit 2, Tab 1, 12.

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33. It was very windy on the beach.29 Some members of the group attempted to play beach cricket for a while, but the wind hampered their game.30

34. Mr Bradley looked at the surf and considered the conditions looked benign, although Dr Hotchkiss described them as “slightly choppy”31 and another person at the beach at that time described the sea as “thumping” and was concerned to see anyone in the water.32 He tested the temperature of the water and found it was warm, so he decided to surf with a body board in the shallows.33 The body board he was using had no leg rope or leash but he was not concerned as he thought there was no risk, given the surf conditions appeared gentle to him.34

35. Dr Vincent and Mr Nelson abandoned their cricket game and also brought body boards into the water.

Only one of those boards had a strap, and it seems that it was not used, in any event.35

36. The three men initially had an enjoyable time catching secondary waves along the shoreline for approximately 50 metre runs.36 They were angling towards the rocks on each run so on exiting the water they would return to the middle of the beach before starting again.37

37. Dr Vincent went out a bit further into the ocean than the others at about the time the surf conditions began to change and the waves picked up.38 Mr Bradley noticed the wind on the beach had picked up, causing the remaining members of their group on the beach to move.39 He indicated to Dr Vincent that they should 29 Exhibit 1, Tab 12 [12].

30 T 20 (Bradley, D.M.).

31 Exhibit 1, Tab 14 [7].

32 Exhibit 1, Tab 17 [2] – [7].

33 T 20 (Bradley, D.M.).

34 T 20 (Bradley, D.M.).

35 Exhibit 2, Tab 1, Attachment 2, 51.

36 T 20 (Bradley, D.M.).

37 T 20 (Bradley, D.M.).

38 T 21 (Bradley, D.M.); Exhibit 1, Tab 12 [18].

39 T 21 (Bradley, D.M.); Exhibit 1, Tab 13 [10]; Tab 14 [15].

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head back to the beach.40 At about the same time as Mr Bradley was saying this, just as they were getting close to the rocky peninsula, they were hit by two large waves.41 Dr Vincent and Mr Bradley lost their boards as a result and had to swim in the now violent surf without flotation aids.42

38. Mr Bradley swam towards the rocks while Dr Vincent, who was further out, tried to swim towards the beach.

Mr Bradley managed to reach the rocks safely, although exhausted.43 He heard his name being shouted and turned and saw Dr Vincent treading water much further out than they had started.44 He could see Dr Vincent was having a difficult time in the surf, even though he was an athlete and very fit.45 The rip was apparently pulling him into the primary waves, which would dump him and then the rip would pull him back out into the next breaking wave.46

39. Mr Bradley called out to Dr Vincent to swim towards the rocks but in response Dr Vincent shook his head, which was the only part of him visible in the water.47 He appeared to be exhausted.48 Another large wave went over him at that time and he disappeared. Mr Bradley thought at first that perhaps Dr Vincent had duck dived under the wave but then became concerned when he did not re-emerge.49

40. By this time Mr Nelson had also managed to swim to the rocks, where he was helped by Ms Bradley.50 He made his way around the rocks and joined Mr Bradley.

They were looking out in the ocean for any sign of Dr Vincent when he suddenly surfaced in the water approximately 10 metres away from them, floating face 40 T 21 (Bradley, D.M.).

41 T 21 (Bradley, D.M.).

42 T 21 (Bradley, D.M.).

43 T 21 (Bradley, D.M.).

44 T 21 (Bradley, D.M.).

45 T 21 (Bradley, D.M.).

46 Exhibit 1, Tab 4. Attachment called ‘Exhibit 6’, 3.

47 T 21 (Bradley, D.M.).

48 T 21 (Bradley, D.M.).

49 T 21 (Bradley, D.M.).

50 Exhibit 1, Tab 13 [16].

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down in the water.51 He had not been underwater long and they thought Dr Vincent might still be able to be saved.52

41. Mr Nelson had some swimming fins he had taken from Ms Bradley. He handed these to Mr Bradley, as he knew Mr Bradley had only just come out of the water and might need them more than he did. Mr Nelson then dove into the water to try to save Dr Vincent while Mr Bradley stopped to put on the fins. Mr Bradley was then hit by another large wave, which washed him off the rocks and into the water without the fins.

42. Mr Bradley and Mr Nelson swam to Dr Vincent and flipped him over so his face was out of the water. They each hooked an arm around Dr Vincent and tried to swim towards the rocks.

43. At the same time another man at the beach saw the three men in distress and tried to use his windsurfer board to go to their aid but was knocked off his board a few metres into the water and had to make his way to rocks while his board floated away.53 Other people on the beach also tried to assist by encouraging the men from the shore and the rocks.

44. However, as Mr Bradley and Mr Nelson tried to reach the rocks with Dr Vincent a triple set of large waves rolled in and hit them. They lost hold of Dr Vincent and were washed apart from each other.54

45. Mr Nelson was calling out to Mr Bradley, asking where Dr Vincent was, as his thoughts were still to rescue him. However, Mr Bradley could not see Dr Vincent and realised at this time that they too were in mortal danger. They agreed to shout out if they saw Dr Vincent but to otherwise head back to the rocks.55 51 T 21 (Bradley, D.M.).

52 T 21 (Bradley, D.M.).

53 Exhibit 2, Tab 15 [10] – [12].

54 T 22 – 23 (Bradley, D.M.).

55 T 23 (Bradley, D.M.).

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46. As the men tried to swim across to the rocks they were both caught in the rip, which was pulling them out to sea.56 Mr Bradley lost sight of Mr Nelson as he fought desperately to make his way onto the rocks. As Mr Bradley reached the final stage of exhaustion and began to succumb to the waves his feet touched a rock.

He realised that he might be able to use the rocks to pull his way out of the water. With enormous effort he gradually pulled himself out of the surging water by taking hold of the rocks, pulling ligaments and tendons in his arms in the process. He eventually crawled up onto the rocks and was assisted by a bystander, Mr Klemm Dykes, to stand.57

47. As Mr Bradley stood up he heard his name being called and turned to see Mr Nelson a considerable distance out in the ocean, in the same place he had earlier seen Dr Vincent struggling with the surf. Mr Nelson called out that he couldn’t swim anymore. Mr Bradley encouraged him to swim to the rocks but he again indicated he couldn’t swim any more. Mr Bradley then shouted to him to float on his back, which Mr Nelson appeared to acknowledge with a nod. However, as he began to roll onto his back he was hit by a very large wave and disappeared under the water.58 That was the last sighting of Mr Nelson.

48. Before Mr Dykes had made his way to the rocks to assist Mr Bradley, he had called emergency services.59 Sergeant Paul Daly, the Officer in Charge of Margaret River Police Station was notified and arranged for the Margaret River Volunteer Rescue Group, Water Police, St John Ambulance team and the SLSWA helicopter to attend the scene.60

49. Sgt Daly arrived at Redgate Beach at about 2pm and was directed to the rocks where he spoke to Mr Bradley, Ms Bradley, Dr Hotchkiss and others who were standing 56 T 23 (Bradley, D.M.).

57 T 23 – 24 (Bradley, D.M.).

58 T 24 (Bradley, D.M.).

59 Exhibit 1, Tab 19 [10] – [11].

60 T 8 (Daly, P.M. (Sgt)).

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there looking for signs of Dr Vincent and/or Mr Nelson.

Sgt Daly arranged for a number of bystanders to take up positions along the coast to observe the water.

50. Mr Dykes, who is a local surfer and qualified surf lifesaver61 was one of the bystanders asked to act as a lookout. He described the ocean at that time as extremely rough, with a 5 metre swell and a 10 foot shorebreak, and the conditions were not good to be in the water.62 Mr Dykes was looking at the water when he saw a person in the water, face down and not moving. He called out to alert people further down the beach.63

51. Sgt Daly heard a shout and saw people pointing to a body lying face down in the water approximately 30 metres offshore.64 A member of the Margaret River Volunteer Rescue Group entered the water and was able to retrieve the body, with the assistance of Sgt Daly and Dr Hotchkiss. Dr Hotchkiss recognised Dr Vincent. He was naked and showing no signs of life.65

52. Dr Hotchkiss and a St John Ambulance officer began performing CPR. They had to clear his airway from fluids several times.66 A defibrillator was brought down and it recorded no electrical activity, which was consistent with the clinical observations of Dr Hotchkiss. Nevertheless, ambulance officers continued CPR all the way to Margaret River Regional Hospital,67 where he was certified life extinct by a hospital doctor.68

53. Meanwhile, the search continued for Mr Nelson in what has been described as “atrocious” ocean conditions.69 The search, which continued for four days,70 involved 61 Exhibit 1, Tab 18 [40] – [42].

62 Exhibit 1, Tab 18 [42] - [44].

63 Exhibit 1, Tab 18 [35] – [37].

64 T 8 – 9 (Daly, P.M. (Sgt)).

65 Exhibit 1, Tab 14 [35] – [36].

66 Exhibit 1, Tab 14 [37] – [39].

67 Exhibit 1, Tab 14 [40] – [45]; Tab 20.

68 Exhibit 1, Tab 4, Attachment called ‘Exhibit 3’.

69 Exhibit 2, Tab 1, 10.

70 T 17 (Daly, P.M. (Sgt)).

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local police, the SLSWA helicopter and Jet Ski Rescue teams and members of the Margaret River Volunteer Rescue Group. Sadly, despite the best efforts of everyone involved, the body of Mr Nelson was not recovered. This was not surprising as the prevailing conditions were so bad that they almost entirely negated the ability of rescue personnel to visually penetrate the water surface to locate submerged objects.71

54. The police from the Missing Persons Unit conducted further investigations and confirmed there has been no financial activity on any of Mr Nelson’s accounts since that day and he has not been sighted since he was seen to go under the water at Redgate Beach.72 Sgt Daly confirmed that as a result of his investigations, he has formed the conclusion that Mr Nelson died in the water that day.73

55. Mr Bradley also confirmed in oral evidence that his daughter had never heard from Mr Nelson again and he had no doubt that Mr Nelson died in the ocean that day.74

CAUSE AND MANNER OF DEATH - DR VINCENT

56. On 11 December 2012 a post-mortem examination was conducted on Dr Vincent by a forensic pathologist, Dr C T Cooke. At the conclusion of the examination Dr Cooke formed the opinion that the cause of death was immersion (drowning).

57. I accept and adopt the conclusion of Dr Cooke as to the cause of death.

58. I find that the manner of Dr Vincent’s death was by way of accident.

71 Exhibit 1, Tab 1, 16.

72 T 17 (Daly, P.M. (Sgt)).

73 T 1 7 (Daly, P.M. (Sgt)).

74 T 26 (Bradley, D.M.).

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CAUSE AND MANNER OF DEATH - MR NELSON

59. By all accounts Mr Nelson was a gentle, loving man with a happy and stable home life and many valued friends.

He was looking forward to the future and making plans.

All the evidence suggests he would make contact with his family and friends if he was able to do so.

60. I am satisfied on the basis of all the evidence before me that the death of Mr Nelson has been established beyond reasonable doubt and I so find.

61. In the circumstances described by the witnesses I am also satisfied beyond reasonable doubt that the cause of Mr Nelson’s death was as a result of immersion (drowning).

62. I further find that the manner of Mr Nelson’s death was by way of accident.

COMMENTS ON SIGNAGE AND OTHER SAFETY MEASURES AT REDGATE BEACH

63. Information provided by SLSWA shows the highest number of WA coastal fatalities for the years 2006 – 2011 (so not including these deaths) was in the Shire of Augusta-Margaret River.75 Further, between January 2007 and 12 March 2013 there were 10 coastal drownings recorded in that region.76 Of those deaths, 90% were males and 40% were in the 20 to 30 year age group.77 Three of the deaths occurred at Redgate Beach, being the deaths of Dr Vincent and Mr Nelson and one other person (whose death occurred in April 2009).78

64. The statistics for the Augusta-Margaret River region over this period match the general pattern for 75 Exhibit 2, Tab 1, Attachment 4, 6.

76 Exhibit 2, Tab 1, 32.

77 Exhibit 2, Tab 1, 32.

78 Exhibit 2, Tab 1, 32.

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drownings on a national basis, with the national statistics in 2012 revealing that 15 - 34 year old males have a high representation in drowning statistics and males generally are overrepresented.79

65. There is always a level of personal responsibility when recreating in the outdoor environment. The Department owes a responsibility to manage visitor risks and to provide an appropriate level of information about those risks. The decision then rests with the individual as to whether it is safe to proceed with their planned activity.

It appears that young men are less likely to factor in their safety when making decisions about when to engage in marine activities.

66. In hindsight, it is clear that Mr Bradley, Dr Vincent and Mr Nelson should not have been body boarding in the water at Redgate Beach that afternoon. In the view of Mr Peck, an experienced person undertaking body boarding in the prevailing conditions would not enter the water without being tethered to their equipment and wearing fins that would assist with propulsion and reduce the likelihood of rapid onset muscle fatigue. I accept Mr Peck’s opinion that the decision to body board with equipment without tethers and not wearing fins at that particular beach was an error in judgment.80

67. However, there is evidence before this Court that they were mature, thoughtful and intelligent people who did not deliberately engage in risky activities. They knew how to swim and anticipated they would be able to cope with ordinary ocean conditions. What they did not know was that this particular beach has inherent dangers, even when conditions seem ordinary, and it can rapidly become even more hazardous if the weather conditions change. The main reason they did not know this was because the signs that should have informed them had been destroyed in a senseless act of vandalism. If they had known this information, there is 79 Exhibit 2, Tab 1, 33.

80 Exhibit 2, Tab 1, 20 – 21.

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a strong possibility they would not have made the fatal decision to go into the surf that day.

68. The relatives of both Dr Vincent and Mr Nelson have expressed a desire for lessons to be learnt from the deaths of their loved ones and steps to be taken to alert visitors to the dangers present at Redgate Beach so that future deaths can be prevented.81

69. Sgt Daly, SLSWA and the Department each reviewed the events of that day and have identified areas where signage at Redgate Beach can be improved, as well as other safety measures that might be implemented.

Signage

70. Before looking at the adequacy of the signage at Redgate Beach, which was a primary focus of much of the reports before the inquest, it is important to note that in the circumstances of this case there were, in fact, no signs on the main pathways to the beach on the particular day that Dr Vincent and Mr Nelson drowned.

Accordingly, it is difficult to comment on whether the content of the signage provided by the Department at that time was adequate to warn beach users of the risks. It is a matter of speculation.

71. My primary concern, given what had occurred to the signs the previous day, was to establish whether the Department has taken steps to ensure that the signs now erected are designed to resist vandalism better than the former signs.

72. It should greatly concern members of the community that vandalism to signage is a constant issue faced by the Department across the State.82 Mr Phillips described maintaining signage in a proper state as a “constant battle” faced by the Department.83 The 81 Exhibit 1, Tab 4, Attachment – called Exhibit 6 – letter from Mr Bradley; Exhibit 7 – Submission from Christine Nelson.

82 T 46 (Phillips, M.).

83 T 46 (Phillips, M.).

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Department maintains a risk sign register to allow close monitoring of the signs to ensure that any missing signs are quickly identified and replaced. The Department also ensures that the districts keep a stock of risk signs in place so that if they are vandalised, a replacement is ready to be installed immediately.84

73. Following the Department becoming aware of the removal of the signs at Redgate Beach around 8 December 2012, new signs were installed on stronger metal poles (rather than the previous wooden ones), which are also fitted with a sleeve that allows them to be quickly replaced if they are damaged.85 Sgt Daly advised that in his view the signs are now anchored correctly.86

74. It does not seem to me that there is much else that the Department can do in that regard. However, I hope that any person who hears of these deaths passes on the message to others that vandalism of signs can have serious consequences and must be actively discouraged, as the best way to manage vandalism is to educate people not to commit it.

75. Having satisfied myself that steps have been taken to try to ‘vandal-proof’ the signs as much as possible, I have also given some consideration to the content of the signage now installed at Redgate Beach.

76. According to SLSWA, rip currents are the number one hazard on Australia’s beaches and are the cause of most rescues and many drowning deaths each year.87 Rip currents often lead to drowning when swimmers attempt to fight the current, become exhausted and begin to panic.88 There is a public misconception that calm water is always safe, but rip currents can be present, even in calm conditions.89 When the weather 84 T 46 – 47 (Phillips, M.).

85 T 46 – 47 (Phillips, M.).

86 Exhibit 1, Tab 23.

87 Exhibit 2, Tab 1, 19.

88 Exhibit 2, Tab 1, 19.

89 Exhibit 2, Tab 1, 19.

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and marine conditions deteriorate, the rips become even more dangerous. It seems the ever present rips are the most dangerous aspect of Redgate Beach. The priority, then, is for the signs at Redgate Beach to warn beach users of the rips and the risk they present.

77. Sgt Daly and Mr Peck expressed some concerns about the adequacy of the signage in place at Redgate Beach in December 2012. However, since that time the Department installed new signage on 16 May 2013.90 There are now a total of 9 signs installed around the outside of the car park on the paths to the beach, as well as an additional sign on the road 1.3kms from the car park.91

78. The sign on the road to the car park informs visitors that they are approaching “Dangerous Coast” and “Lives have been lost.”92 Other signs in the car park and along the beach paths warn of:

• Strong rips;

• Large waves and swells;

• Slippery rocks and loose surfaces; and

• Sharks, as well as indicating that the beach is unpatrolled and providing the emergency services number.93

79. Importantly, three signs situated in key spots along the beach pathway warn specifically of “Dangerous Rip Risk” with a large danger symbol, as shown below, and indicating on the signs the location of the rips, as well as that lives have been lost there.94 90 Exhibit 2, Tab 9, Attachment 3, 2.

91 Exhibit 2, Tab 9, Attachment 3, Figure 1.

92 Exhibit 2, Tab 9, Attachment 3, Figure 2.

93 Exhibit 2, Tab 9, Attachment 3, Figure 3.

94 Exhibit 2, Tab 9, Attachment 3, Figures 8, 10 & 11.

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The above photograph depicts the warnings signs which can be found in Exhibit 2, Tab 9, Attachment 3

80. The Department has also designed a new rip safety sign/poster that informs beach users on how to escape a rip.

It is intended that the sign will be used at Redgate Beach and other appropriate locations.95 This sign provides an important piece of information at a beach where rips are permanently present and will be a very helpful addition to the other signs in place.

The above depicts the safety warning which can be 95 Exhibit 2, Tab 9, Attachment 3, 9 - 10.

found in Exhibit 2, Tab 9, Attachment 3 Inquest into the death of Ian Bradley VINCENT and the suspected death of Kane Edwin NELSON 21

81. Sgt Daly confirmed at the inquest that he is satisfied that the signage now in place at Redgate Beach is appropriate and provides ample information for visitors to the beach to make informed decisions.96

82. Mr Peck from SLSWA accepted that the new signage is largely in compliance with the Australian Standards, other than the shape of the symbols.97 He expressed SLSWA’s preference for the signage to conform to Australian standards in all its features, so that there is uniformity of signage throughout Australia, but he accepted that it is difficult to comment on whether the Department’s use of a square shape would have any material impact on someone noticing a sign.98

83. Mr Phillips explained that one difficulty the Department had in adopting the Australian Standards for marine signage is that they have to manage a large area of both marine and terrestrial environments, so they need to find a sign system that works in both environments.99 The Department also takes the firm view that the use of a square symbol actually allows a bigger graphical image to be presented on the sign versus the use of a triangle or diamond and is, hence, more visible.100

84. In the context of this inquest, where the issue was primarily about the absence of signage, there is little purpose in my engaging in a close analysis of the differences between the Australian standards and the Department’s Risk Symbol Index.101 All of the parties appear to be in agreeance that the new signage installed at Redgate Beach is a significant improvement over the former signage in ensuring visitors are warned of the risks of engaging in marine activities at Redgate Beach.

I agree that the new signage is appropriate and comprehensive, particularly if the Department follows through with its commitment to install their newly 96 T 15 (Daly, P.M.); Exhibit 1, Tab 23.

97 T 32 – 34 (Peck, C.W.).

98 T 33 - 34 (Peck, C.W.).

99 T 45 (Phillips, M.).

100 T 46 (Phillips, M.).

101 Exhibit 6.

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designed ‘how to escape a rip’ sign. I am satisfied that the signage is likely to achieve the hope of the deceased’s families that visitors will be alerted to the dangers so that future deaths at the beach may be prevented.102

85. However, separate to the signs installed at Redgate Beach, Mr Peck recommended that the Department consider the installation of approach signs on the roadway into the Redgate Beach car park that communicates that this beach does not have lifesaving services and where beaches with lifesaving services can be accessed (such as Margaret River Mouth).103

86. I agree with Mr Peck’s suggestion that this additional information might be helpful for visitors to know, as it may encourage them to swim at a more appropriate location. Locating it on the roadway, so that the information is communicated to people while they are still in their vehicle and in a good position to continue on to another location, may well be useful in that regard.

87. Mr Phillips indicated that the Department had no resistance to that suggestion and would be happy to have an open discussion with SLSWA and other relevant parties in that regard, particularly as a review of the current signage needs to be undertaken in any event due to some new symbols that have been adopted by the Department.104 It is pleasing to hear that the Department is open to considering this suggestion and I encourage SLSWA to discuss the matter with the Department and see if such a sign can be agreed upon.

102 Exhibit 1, Tab 4, Attachment – called Exhibit 6 – letter from Mr Bradley; Exhibit 7 – Submission from Christine Nelson.

103 T 32 (Peck, C.W.).

104 T 49 (Phillips, M.).

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Direct Beach Access

88. Redgate Beach lacks direct beach access and launch capabilities of powered rescue craft. This lack of direct accessibility requires rescue assets, which are often trailered, to be launched from nearby launching facilities such as Gnarabup Boat Ramp (approximately 6 kilometres away).105 Mr Peck advised that this presented problems for the rescue teams in terms of response times and also jeopardised the safety of the response team members at times, during this incident.106 Bearing in mind that the search exercise lasted a number of days, the difficulties with access becomes even more significant.

89. SLSWA recommended that the Department should give strong consideration to improving direct beach access for vehicles and rescue assets as it will improve the incident response times and incident management opportunities.107

90. Mr Phillips advised in his report that in order to create beach access for emergency vehicles at Redgate Beach the walk trail leading to the beach would need to be widened and the path around the impeding granite headland realigned. There is a former 4WD track to the east of the beach, around the back, but it would also require a significant widening of the track in order to gain beach access.108

91. The Department has indicated that it is happy to explore these options, but they need to assess the management implications for uncontrolled 4WD access to the dunes resulting from improved emergency vehicle access and the costs involved in maintaining tracks, as well as any issues raised by the presence of rare flora.109 Mr Phillips suggested that usually there is a way of getting access to the beach, but acknowledged 105 Exhibit 2, Tab 1, 16.

106 T 40 - 41 (Peck, C.W.).

107 Exhibit 2, Tab 1, 16, 44.

108 Exhibit 2, Tab 9, Attachment 5, 4.

109 T 48 (Phillips, M.).

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that there might be a communication issue with other agencies that needs to be improved in that regard.110

92. While I appreciate that the Department has to factor in its legislated responsibility to protect local flora and fauna, and also the need to minimise the risk of unauthorised people utilising emergency vehicle access routes for their own purposes, it seems to me that the dangerous nature of Redgate Beach and its remote location from other services makes it a priority that direct beach access be available to emergency services.

It is a necessary improvement to ensure the safety of members of search and rescue organisations, as well as to reduce the incident response time.

RECOMMENDATION I recommend that the Department of Parks and Wildlife take steps to create and maintain a roadway to facilitate direct beach access for emergency vehicles and other lifesaving assets and equipment to Redgate Beach and to ensure that the relevant organisations are informed of how the roadway can be accessed.

Lifesaving Equipment

93. Sgt Daly recommended in his report that consideration be given to the installation of life preserving equipment at Redgate Beach that may be utilised in an emergency.111

94. Mr Phillips reported that the Department experiences similar problems with vandalism in relation to public rescue equipment as they experience with signs. They have also experienced ongoing problems with misuse and theft of public rescue equipment.112 It is an 110 T 48 (Phillips, M.).

111 Exhibit 1, Tab 3, 10.

112 Exhibit 2, Tab 9, Attachment 5, 3.

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ongoing challenge for the Department to find equipment that is useable but resistant to vandalism.113

95. For example, the Department trialled silent sentry devices along the Albany coast, which automatically activate an EPIRB system to alert the rescue authorities when the floats are released. Unfortunately, floats have been removed and stolen and the Albany police had to request the Department to remove the devices due to malicious activations of the EPIRBS on several occasions, leading to a waste of emergency services time and resources.114

96. The Department is currently trialling a new form of Angel Ring flotation device in the Albany area (and proposes to do so along the Esperance coastline),115 which has a Geo-tracker built into the device that is activated if the flotation ring is removed, allowing it to be tracked. The Department has expressed its willingness to install a similar device at Redgate Beach once they are confident that it works and won’t go missing or be rendered unusable due to vandalism.116

97. Mr Peck from SLSWA acknowledged that whilst the placement of public rescue equipment at Redgate Beach might be a valuable contribution to prevention and rescue, the costs of implementing and maintaining this type of service might not be justified given the number of people who currently visit Redgate Beach is not large.117

98. In my view there is merit in the Department exploring the possibility of installing some sort of rescue devices at Redgate Beach, but I accept that there is little purpose in the Department installing such equipment until it is confident it can be managed and maintained in a reasonable and reliable way.

113 T 47 (Phillips, M.).

114 T 47 (Phillips, M.); Exhibit 2, Tab 9, Attachment 5, 3.

115 Exhibit 3, 3.

116 T 48 (Phllips, M.); Exhibit 2, Tab 9, Attachment 5, 3.

117 Exhibit 2, Tab 1, 41 - 42.

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Information on the Internet

99. One other possible area for improvement raised by Mr Peck in his report was in relation to education and information. As Mr Peck noted, many tourists research areas of interest on the internet to plan their itinerary.

SLSWA suggests that this is an opportune time to provide information to members of the public about beach safety generally and the safety of particular beaches, to allow each individual to make informed decisions regarding which beaches to visit and their actions while at the beach.118

100. The timing can be important as, in the experience of SLSWA, once people make a plan, such as to go to the beach, they will often persevere with that plan despite the fact that the conditions on the particular day may not match their capability and experience.119 Mr Peck did not suggest that this is what occurred in relation to Dr Vincent and Mr Nelson, but I accept his proposition that the more information that is available to beachgoers prior to attending the beach, the better informed their decisions will be when at the beach.

101. One good information source is the Surf Life Saving Australia beach safety website www.beachsafe.org.au.

This is a ready-made information source that provides details on beach locations and conditions. Apparently there are also steps being taken for a BeachSAFE smartphone/tablet application to allow quick translation of local signage messages into languages other than English. SLSWA recommends that the Department and other stakeholders promote BeachSAFE as a web information source and a smartphone application.120

102. Since this incident the Department has taken up this suggestion and contains a reference to the BeachSAFE 118 T 38 – 40 (Peck, C.W.) 119 T 40 (Peck, C.W.).

120 Exhibit 2, Tab 1, 39.

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website on its website.121 I have looked at the website and it clearly directs visitors to the website and suggests that visitors should check this information and ensure they are familiar with it. It also advises that almost without exception the beaches in parks are unpatrolled, and cautions visitors not to underestimate the risks of coastal environments.122

103. The Shire of Augusta and Margaret River, however, has not. The website does indicate that a lifeguard service is provided at the Margaret River Mouth beach from December through to March and during the Easter long weekend, which is helpful information. It also has a section on beach safety, which appears to be predominantly focussed on sharks, but also includes that details on patrols for local beaches can be obtained from the Surf Life Saving WA web site, with a link provided. 123 From that website, the BeachSAFE website can be accessed. However, as Mr Peck stated, the information needs to be front and centre rather than buried down, requiring a number of clicks, or people will simply not access it.124

104. Although the management of Redgate Beach is the responsibility of the Department it does fall within the region of the Shire and its constituents are members of the volunteer rescue group who assisted in the rescue of Dr Vincent and search for Mr Nelson that day.

Accordingly, it is in the interests of the Shire to support the Department and SLSWA in their endeavours to improve safety at Redgate Beach. The Shire could do this by providing a more direct link on its website to the BeachSAFE website accompanied by an explanation as to the risks presented by the coastal environment and the benefits of accessing the information provided on the website when planning their trip to the South-West.

121 T 35 (Peck, C.W.).

122 www.parks.dpaw.wa.gov.au/know/natural-remote-area-risks.

123 www.amrshire.wa.gov.au/recreation-and-tourism/beaches-and-rivers/beach-safety 124 T 36 (Peck, C.W.).

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105. The Shire was not represented at the inquest, but a copy of this finding will be provided to it for its consideration.

CONCLUSION

106. On 8 December 2012, Dr Ian Vincent and Mr Kane Nelson drowned at Redgate Beach. Both of these young men had dreams of marrying and having children and living a full life. Those dreams were cut short by the unanticipated events of that day.

107. Their deaths are a reminder to all Western Australians and visitors to this State that the Indian Ocean, whilst beautiful, can be treacherous and must always be treated with caution.

COMMENDATION

108. The volunteers and staff from all the agencies involved risked their own lives by entering the water and going into the hazardous conditions prevailing at the time to undertake the marine search and rescue operation.125 I agree with Mr Peck from SLSWA that each person is to be commended for their bravery and actions in recovering the body of Dr Vincent and the continued attempts to recover the body of Mr Nelson.126

109. In addition, Mr Bradley described Mr Nelson’s behaviour in giving Mr Bradley his fins and diving back into the water to try to save Dr Vincent as “courageous”.127 I agree with him. Mr Nelson died in the course of a selfless act to try to save the life of another. I respectfully suggest that Mr Nelson’s family and friends give consideration to nominating him for consideration by the Australian Bravery Decorations Counsel for a posthumous Australian Bravery Award, via the Honours 125 Exhibit 2, Tab 1, 10.

126 T 29 (Peck, C.W.); Exhibit 1, Tab 1, 10.

127 T 22 (Bradley, D.M.).

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Secretariat at Government House in Canberra, if they have not already done so.

S H Linton Coroner 4 August 2014 Inquest into the death of Ian Bradley VINCENT and the suspected death of Kane Edwin NELSON 30