Inquest into the Death of Matthias Ashley BACHE

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

RECORD OF INVESTIGATION INTO DEATH Ref No: 32/17 I, Evelyn Felicia Vicker, Deputy State Coroner, having investigated the suspected death of Matthias Ashley BACHE with an Inquest held at Perth Coroners Court, Court 51, Central Law Courts, 501 Hay Street, Perth, on 11 August 2017 find the death of Matthias Ashley BACHE has been established beyond all reasonable doubt, the identity of the deceased was Matthias Ashley BACHE and that death occurred on 8 March 2016 in the seas off Wyadup Rocks, Yallingup, as a result of Drowning in the following circumstances:- Counsel Appearing: Sergeant L Housiaux assisted the Deputy State Coroner Table of Contents Inquest into the suspected death of Matthias Ashley BACHE (F/No: 603/2016) page 1.

INTRODUCTION On 8 March 2016 Matthias Ashley Bache (the deceased) jumped from the Wyadup Rocks into the water in the channel connecting Injidup Natural Spa to the Ocean. He surfaced and attempted, unsuccessfully, to access the rocks at the water line. The current swept him out to sea and despite an extensive sea, land and air search, he was never seen again.

He was 25 years of age.

The Office of the State Coroner (OSC) received a letter from the deceased’s mother on 31 May 2016 asking there be an enquiry into the death of her son at Injidup Beach, Yallingup.

Pursuant to section 23 (1) of the Coroners Act 1996 (WA) the State Coroner had reasonable cause to suspect the deceased had died and that the death was a reportable death. She directed the suspected death of the deceased be investigated. Where the State Coroner has given such a direction a coroner must hold an inquest into the circumstances of the suspected death to establish beyond all reasonable doubt the deceased has died, and if possible how death occurred and the cause of death.

Inquest into the suspected death of Matthias Ashley BACHE (F/No: 603/2016) page 2.

A report outlining the investigation into the suspected death of the deceased was compiled by Senior Constable Adrian Koekemoer of the Dunsborough Police Station and he provided evidence at the inquest conducted on 11 August 2017.1 Following the deceased’s disappearance there was a significant land, sea and air search, but no trace of the deceased was found following his disappearance minutes after he jumped from the rocks.

BACKGROUND The Deceased The deceased was born on 4 January 1991 in Adelaide, South Australia. He had three siblings and in 2005 his family moved from New South Wales to Western Australia.

The deceased worked as a refinery process operator at Worsley Alumina Pty Ltd and was two years into the training required to become a sky diving instructor. He enjoyed outdoor activities verging on the extreme sports scenarios and the thrills those activities involved. He was known to surf, snowboard, sky dive and rock jump into the ocean.2 1 Ex 1, attachments 1-22 2 Ex 1, tab 4 & 5 Inquest into the suspected death of Matthias Ashley BACHE (F/No: 603/2016) page 3.

The deceased was considered to be fit and healthy although he had suffered with a situational mood disorder in 2011.3 At the time of his death the deceased was living in Quedjinup, Dunsborough, with a friend, Arthur Parsons, and was largely enjoying life. He had last spoken with his family on a group chat on Facebook messenger shortly before his death and there were no concerns for his wellbeing.

The deceased had jumped from the Wyadup Rocks previously and he had a preferred jumping point. In the weeks shortly before his death he and his friend had also jumped from Sugar Loaf Rock and The Bridge at Canal Rocks, Yallingup.4 Wyadup Rocks Wyadup Rocks form part of a rocky shoreline approximately 5 kilometres south of the town site of Yallingup in the south west of Western Australia. The coastline is spectacular and contains beautiful beaches between rocky promontories. It is very popular with local residents and tourists.

3 Ex 1, tab 11 4 Ex 1, tab 5 Inquest into the suspected death of Matthias Ashley BACHE (F/No: 603/2016) page 4.

Exhibit 1, Tab 20, Photograph 1 – Natural Spa, Wyadup Rocks Due to the rocky formation at Wyadup Rocks a natural spa has developed in the form of a large rock pool replenished with sea water according to the surge of the waves against the rocks. The water enters and exits the rock pool through many fissures in the rocks and one main channel out into the ocean. The wave surge causes the spa effect in the rock pool and the water in the channel reflects the ocean conditions. It can be very calm and relatively safe or very choppy and dangerous due to the surrounding rocks. The pool is called both Injinup and Wyadup Natural Spa and is a known attraction capable of providing an uplifting experience.

As with most of the WA coastline conditions can become quite treacherous in and around the rocky shoreline and every year people climbing the rocks, whether it be fishing Inquest into the suspected death of Matthias Ashley BACHE (F/No: 603/2016) page 5.

or thrill seeking, loose their footing and get swept under the water, often never to be seen again, despite significant signs warning people of the dangers of irregular waves.

Exhibit 1, Tab 19, Photographs 1 & 5 – warning signs in the area Inquest into the suspected death of Matthias Ashley BACHE (F/No: 603/2016) page 6.

Despite the warnings on the pathways into the spa, including warnings about the erratic wave pattern, an activity has developed for people to jump from the rocks into the channel replenishing the spa, where the water is expected to be deeper. The fact this is dangerous is obvious because of the risk from the rocks comprising the channel.

Anecdotally, this risk taking behaviour is so popular someone has marked spots on the rocks in an attempt to suggest it is the safest place from which to attempt the jump. Any jump can be dangerous due to the rocky terrain and the difficulty with determining where exactly rocks are under the water.

The Disappearance 8 March 2016 was a Tuesday. That afternoon, sometime between 4-5 pm, the deceased and his friend, Arthur Parsons, drove in the deceased’s car to the Wyadup Rocks car park. At the car park they parked and their intention was to jump from the Wyadup Rocks into the ocean at the entrance to the channel to the spa.

Inquest into the suspected death of Matthias Ashley BACHE (F/No: 603/2016) page 7.

Exhibit 1, Tab 20, Photograph 2 – area where deceased jumped showing roughness of ocean The deceased had done this before and there was a particular spot from which he normally jumped. The conditions on that day were not apparently rough out to sea, however, there appeared to be a strong swell and other visitors to the area at that time commented the water crashing through the channel into the rock pool, was really forceful. It would usually be possible for visitors to sit underneath the channel to the rock pool but on this day it was impossible to sit there because the water coming through the channel was too rough.5 The deceased and Mr Parsons walked from the car park down to the spa and then climbed up the rocks into the channel where the water comes through to the inland side 5 Ex 1, tab 6 & 7 Inquest into the suspected death of Matthias Ashley BACHE (F/No: 603/2016) page 8.

of the channel. Mr Parsons commented to the deceased he believed the water was too rough for a normal jump and he advised the deceased he was not going to jump into the water.

The deceased described the conditions as beautiful and told his friend he was going to jump in anyway.

The deceased jumped into the water.

Mr Parsons saw the deceased surface from the water and try to hold onto the rocks, but he was unable to grip the rocks because the swell was too big. Due to the proximity of the deceased to the rocks Mr Parsons told him to swim out because it was not safe to exit through the rocks.

Mr Parsons knew the deceased was a very fit, strong and able swimmer and believed he would be able to complete the swim while he went for help.

Mr Parson ran back to the spa area and asked the people there if they could help him by contacting the emergency services to help rescue the deceased. The women at the rock pool had only noticed the deceased and his friend walk up the rocks a very short time before, approximately 5-10 minutes.

The group of women at the spa, Sarah Holloway, Anna Curtis and Mara Debus had arrived at the spa Inquest into the suspected death of Matthias Ashley BACHE (F/No: 603/2016) page 9.

approximately an hour earlier than the deceased and his friend and were enjoying the spa although noting the conditions were unusual.6 Ms Holloway immediately dialled ‘000’ and her phone records the call as having occurred at 5.10 pm. Her friends, Ms Curtis and Ms Debus, ran up the rocks in an attempt to locate the deceased.

Mr Parsons ran back to the top of the rocks and could still see the deceased. He attempted to get down to the water but found the rocks were too slippery to reach the water line. Ms Holloway thought Mr Parsons was intending to go in after the deceased and relayed to him emergency services were telling him not to go into the water. Mr Parsons described the deceased as still face up and kicking around for a while, but drifting firstly towards the bay and then further out to sea.

Ms Curtis and Ms Debus had also run up to the rocks after Mr Parsons and they both saw the deceased in the water.

They could only see his head and he was face down.

Ms Debus described the deceased as face down in the water and not moving.7 He was about 15-30 metres from the rocks moving north west towards Canal Rocks.

6 Ex 1, tab 6 7 Ex 1, tab 8 Inquest into the suspected death of Matthias Ashley BACHE (F/No: 603/2016) page 10.

Ms Debus and Ms Curtis decided to go to the car park and wait for emergency services and told Ms Holloway she was to stay with Mr Parsons to make sure he was alright.

Ms Holloway had been attempting to describe to emergency services where they were which is why Ms Debus and Ms Curtis decided to go and wait for them to arrive.8 Mr Parsons was concerned he saw a shark approximately 15 metres from the deceased, however, there was some dispute as to whether it was a shark or a pod of dolphins which were observed a few moments later.9 On the way to get help for Mr Parsons, Ms Curtis and Ms Debus came across some people in the car park. They explained to them there was someone in the water and they were attempting to get help. They asked if any of those people were strong enough in the water to assist in recovering the deceased.

Ms Curtis and Ms Debus drove towards Caves Road and Ms Curtis left Ms Debus at the top of the Wyadup Road to signal for the ambulance when it arrived. Ms Curtis continued onto Canal Rocks to see if there was anyone there with a boat to help. She also tried Smiths Beach but was not able to find anyone.10 8 Ex 1, tab 6, 7 & 8 9 Ex 1, tab 6 10 Ex 1, tab 7 Inquest into the suspected death of Matthias Ashley BACHE (F/No: 603/2016) page 11.

Ms Curtis then drove back to the car park on Wyadup Road and found the ambulance already there.

Ms Debus had taken the ambulance paramedics to where people had last seen the deceased, but no one could still see him. Ms Holloway was there with Mr Parsons.

The two men Ms Debus and Ms Curtis had seen in the car park were Cameron Smith and Rhys Doherty. They had taken their surf boards and run down the path to the ocean side of the spa, to where Ms Holloway was pointing towards the water while explaining that was near where the deceased was last seen. They saw Mr Parsons pointing into the water as well. Both Mr Doherty and Mr Smith saw the deceased in the water. He was floating face down and not moving approximately 50 metres off shore. They observed he was being swept towards Canal Rocks.

Mr Smith and Mr Doherty ran down to the exit from the rock pool to the ocean and paddled out of the key hole in the direction in which they had seen the deceased. By the time they were out in the open water they could no longer see the deceased. Mr Smith and Mr Doherty remained in the water for about 15 minutes searching for the deceased but were unable to see him, partly because of the glare on the water. They both swam back to shore and at that time Inquest into the suspected death of Matthias Ashley BACHE (F/No: 603/2016) page 12.

police and a helicopter were already searching the area for the deceased.11 The Search The ‘000’ call originally made by Ms Holloway for emergency services initially alerted St John Ambulance (SJA) service, who had dispatched an ambulance and rescue helicopter rescue 652 to the area. The SJA centre also contacted the Yallingup Police to attend Wyadup Rocks, and at approximately 5.24 pm, the Water Police stationed in Fremantle were made aware of the fact there was a person, suspected drifting, in the ocean.12 In addition to the rescue helicopter, the Water Police initiated a marine search and rescue (MSAR) operation which continued until the end of Thursday, 10 March 2016.

The search was overseen by Water Police Senior Constable Martin Allen as the on duty Search and Rescue Mission Controller (SARMC). Initial control of the incident was coordinated by Dunsborough Police until the water police had a comprehensive presence in the area. They attended at the Wyadup Rocks with the ambulance and took command of the immediate vicinity.

The Water Police alerted and deployed search and rescue units through the Volunteer Marine Search and Rescue 11 Ex 1, tab s 9 & 10 12 Ex 1, tab 3 Inquest into the suspected death of Matthias Ashley BACHE (F/No: 603/2016) page 13.

(VMSAR) groups at Margaret River and Cape Naturaliste (Dunsborough). The search and rescue units were asked to commence a search for the deceased between Wyadup Rocks and Canal Rocks as the last position in which the deceased had been seen and the drift of the ocean in that area.

The sea conditions were described as good.

The rescue helicopter completed an aerial search by 6.50 pm then used night vision goggles for a further 30 minutes.

The Margaret River and Cape Naturaliste VMSAR Vessels searched until approximately 8.00 pm without locating the deceased. There was also a private vessel assisting.

The search on the evening of 8 March 2016 was ceased at 7.50 pm. The area covered in that time is depicted on the attached diagram.

Inquest into the suspected death of Matthias Ashley BACHE (F/No: 603/2016) page 14.

Exhibit 1, Tab 3, Page 8 – Tracplus screen shot showing Margaret River (magenta) & Cape Naturaliste (green) VMR vessel search for Day 1 on 8 March 2016.

Sergeant Michael Wear of the Water Police was recalled to duty at 7.18 pm on 8 March 2016 to commence planning of search operations for the following day as SARMC. Both Senior Constable Allen and Sergeant Wear have qualifications in public safety and police search and rescue management, as well as commercial vessel operator qualifications.

Inquest into the suspected death of Matthias Ashley BACHE (F/No: 603/2016) page 15.

It was agreed between the OIC of the Dunsborough Police Station and the Water Police that SARMC would have overall coordination of the event from the morning of 9 March 2016. The OIC of the Dunsborough Police, Sergeant Bahen, took on the position of Police Forward Commander and he nominated a family liaison officer.

Additional VMSAR groups and lifesaving groups were included in the search effort and additional air support from the Police Air Wing and the Bunbury Aero Club. In addition observers for the aircraft were arranged from the State Emergency Service (SES).

SARMAP, a computer system designed to assist with the prediction of the movement of objects through and on the water, was used in an effort to map the deceased’s expected drift in the water. The computer program indicated a slow rate of drift, largely towards the shoreline within the immediate area and some drift towards the north-west. The search areas were selected using the drift mapping as a guide. In addition the Water Police divers were arranged to attend the search area for an underwater search.

The search on 9 March 2016 commenced at approximately 7.00 am. Due to the locality it was determined the search was within state capabilities and Canberra was not involved.

Inquest into the suspected death of Matthias Ashley BACHE (F/No: 603/2016) page 16.

The advice of a survival expert, Dr Paul Luckin, Australia Naval Reserve, was contacted for advice about the expected success of recovering the deceased alive in the conditions at the time. It was estimated the deceased had a 30% chance of survival if he was in the water. He would be incapacitated by midday on 9 March 2016 if he was not located, and he had a negligible chance of surviving beyond 3.00 pm that day. The reasons for the expected lack of survival were fatigue and hypothermia.13 On 9 March 2016 there were four search areas involving four search and rescue vessels with five jet skis. There was also one aircraft searching the most expected area for the deceased. The pilot of that air craft described the visibility as good, but with difficulty in seeing a person in the water.

The jet skis were used to complete intensive water line searches.

The deceased was not located and the search operation on 9 March 2016 ended at 5.00 pm. In that time the expected search areas had been searched eight times. The Dunsborough Police had organised land searches along the shorelines in the area in the event the deceased had been washed to shore.

The timeframe for survival expired on 9 March 2016 and the search on 10 March 2016 continued in the hope he had 13 Ex 1, tab 3 Inquest into the suspected death of Matthias Ashley BACHE (F/No: 603/2016) page 17.

somehow survived. The water police divers searched the underwater areas between Wyadup Rocks and Canal Rocks to see if the deceased could be located. Again nothing was located on 10 March 2016.

By the end of the third day it was concluded that it was unlikely the deceased was still on the surface of the water in the search area. Once drowned people in the water usually submerge and may also be the victim of predation. It was believed there was no prospect of finding the deceased alive, nor floating on the surface of the water.

Searches along the shoreline continued, but no trace of the deceased has been found or sightings recorded since 8 March 2016.

SIGNAGE The signage on the way to the Wyadup Rocks above the channel to the spa is quite extensive. The signs are both in the form of “Coast Risk Area” and “Warning, Rock fishing in this area can be dangerous. Lives have been lost”. The signs warn of both dangerous rips off the beach and freak waves and swells. While none of them specifically refer to rock jumping, the stylised diagrams on the danger warning signs make it quite clear that the conditions in the water can be perilous.

Inquest into the suspected death of Matthias Ashley BACHE (F/No: 603/2016) page 18.

There could be a concern the warnings are only in English, however, the diagrams depict freak waves well enough for any person with visual ability. They compensate for the lack of other languages.14 A concern with the signage with respect to the deceased’s activities specifically is that it is not referred to or depicted.

Obviously, it would appear to be inherently dangerous, however, foreign tourists may observe people rock jumping and think it is safe because it is not mentioned. The fact a spot has been marked on the rocks to provide guidance for a “safe take off jump” appear to imply jumping may be acceptable.15 The concern is less for the locals, which the deceased was, but more for tourists and those not familiar with the WA coastal conditions. The signage is clear enough for rock fishing, but not for the perils of deliberately jumping into the water without knowledge of what lies beneath on a rocky coastline.

However, the fact of the warnings should have impressed upon anybody, from any background, there were dangers associated with the coast. A stylised picture of rocks below the surface and a cross through a person jumping may be a consideration.

14 Observations of non-English speaking witnesses in inquests conducted in Albany 20-24 November 2017 with respect to rock fishing.

15 t 11.08.17, p8 Inquest into the suspected death of Matthias Ashley BACHE (F/No: 603/2016) page 19.

There have been a number of inquests recently, specifically dealing with the Albany coastline where the dangers of rock fishing were explored. That is a situation where people inadvertently come into difficulties while pursuing another activity.

The deceased in this case, specifically intended to jump from the rocks, there was nothing unintentional about his actions. I accept entirely he did not intend to die. He did, however, appreciate that it was dangerous. In the event he did not, the comment of his friend Mr Parsons that he did not intend to jump would have given the deceased cause for pause. It seems the deceased was seduced by the beauty of the ocean, which it undoubtedly is, and wanted to experience the exhilaration of being part of that force.

I note the deceased’s mother would like signage outlining how many people have died as the result of ending up in the ocean. The warnings at Wyadup Rocks certainly indicate lives have been lost, but do not specify a number. The signage north of Carnarvon in the vicinity of the “blow holes” and Quobba are as explicit as the deceased’s mother would wish, and actually list the names and dates of people lost from the rocks in that area. There is little evidence that has deterred rock fishermen who continue to die when falling into the ocean. I am not convinced any specificity about deaths would discourage those young people who Inquest into the suspected death of Matthias Ashley BACHE (F/No: 603/2016) page 20.

enjoy the thrill of pitting themselves against the environment.

Education on line, when people are looking for tourist spots, and education in schools, is probably more dissuasive than signs located at an area which people have visited already intending to conduct or experience a specific activity. The deceased had rock jumped from that area before, he was a very experienced and talented surfer and swimmer and was, I believe, swept up in the magic of the moment. Realistically if anyone was to survive it could be expected to be the deceased.

It was a very tragic outcome, but I am not of the view additional signage would have dissuaded the deceased from his jump. Knowledge of the deceased’s death, however, may prevent others from taking the same risk and some way of acknowledging his death at the scene may be appropriate.

CONCLUSION AS TO THE DEATH OF THE DECEASED I am satisfied the deceased was a 25 year old male, experienced with the ocean, surfing, and swimming. He was familiar with Wyadup Natural Spa and visited Wyadup Rocks with the intention of jumping from the rocks into the ocean below, at the entrance to the channel leading to the spa. It was an activity he had performed before from the same location, as had others.

Inquest into the suspected death of Matthias Ashley BACHE (F/No: 603/2016) page 21.

On 8 March 2016 visitors to the area conceded the ocean did not look particularly rough, but there was a high swell.

The swell caused the water running from the channel into the spa, before it exited back out into the ocean via a different channel, to be so forceful as to prevent people from sitting underneath the waterfall.

The deceased and his friend reached the spot from which the deceased and his friend usually jumped into the channel and the deceased’s friend commented he did not believe they should jump. The deceased was clearly exhilarated by the scene and after informing his friend that “it was beautiful” he jumped from his normal spot on the rocks to the water below.

The deceased surfaced, but it would seem he was impaired in some way because he was unable to pull himself up out of the water as usual. He appeared to be conscious at that stage because his friend saw him struggling to grip the rocks, but unfortunately he was unsuccessful and drifted out to sea, north-west along the coastline. There are a number of ways in which sudden immersion in cold water can incapacitate a person’s normal ability to swim.16 The next time anybody was aware of the deceased he appeared to be face down in the water and no longer attempting to swim. It would appear he was unconscious 16 Evidence of Dr Paul Luckin in Albany in November 20-24, 2017.

Inquest into the suspected death of Matthias Ashley BACHE (F/No: 603/2016) page 22.

by that stage and once unconscious it would have been improbable he would have survived for more than a minute or two without an appropriate life jacket.

I am satisfied the deceased’s friend raised the warning as quickly as possible and, to their credit, surfers immediately looked for the deceased, spotted him in the water, and entered the water themselves in an attempt to rescue him.

Unfortunately at water level visibility was restricted and they were unable to find the deceased, but they should be commended for their efforts as first responders on behalf of the deceased, as his mother acknowledged, and on behalf of the community.

The alarm was raised and a search coordinated for the rest of that evening by WAPol and local marine and rescue groups. The deceased was not located. A survival expert advised he was unlikely to survive more than 24 hours in the water. The search continued for three days.

No trace of the deceased was found and it is likely he sank and became lodged along the rocky shore out of sight. I am satisfied that by that time the deceased had already died as the result of drowning, if not injuries.

No one has heard from the deceased since that time and I am satisfied he was close enough to his family that had he survived he would have contacted them. There is no Inquest into the suspected death of Matthias Ashley BACHE (F/No: 603/2016) page 23.

evidence the deceased wished to disappear and I do not believe that to be the case. Consequently I am satisfied beyond reasonable doubt as to the death of the deceased.

MANNER AND CAUSE OF DEATH I am unable to speculate further on the cause of the deceased’s death. It would appear he was probably incapacitated in some way as a result of his jump into the water and this caused him to be unable to access the rocks to pull himself out in his usual manner and resulted in his drowning. It may have been that merely because he was in the water he became unconscious and drowned.

I am satisfied beyond all reasonable doubt the deceased died shortly after jumping into the water below the Wyadup Rocks on 8 March 2016 as the result of drowning.

I find death occurred by way of Misadventure.

E F Vicker Deputy State Coroner 7 December 2017 Inquest into the suspected death of Matthias Ashley BACHE (F/No: 603/2016) page 24.