Coroners Act 1996 [Section 26(1)] Western Australia
RREECCOORRDD OOFF IINNVVEESSTTIIGGAATTIIOONN IINNTTOO DDEEAATTHH Ref No: 23/18 I, Barry Paul King, Coroner, having investigated the suspected death of Jeffery Thomas Doyle with an inquest held at the Perth Coroner’s Court on 11 July 2018, find that the death has been established beyond all reasonable doubt and that the identity of the deceased person was Jeffery Thomas Doyle and that death occurred on or about 17 October 2016 in the waters of the Indian Ocean off Bunbury from an unknown cause in the following circumstances: Counsel Appearing: Sergeant L Housiaux assisting the Coroner TTaabbllee ooff CCoonntteennttss Inquest into the suspected death of Jeffery Thomas Doyle 1489/2016
IINNTTRROODDUUCCTTIIOONN
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Jeffery Thomas Doyle (the deceased) lived in Binningup with his wife, Julie Doyle. He was last known to be alive when on 17 October 2016 he spoke to Mrs Doyle by phone from his boat off the Bunbury coast. He planned to return home that evening but failed to do so. Early on 19 October 2016, Mrs Doyle contacted the Bunbury Police Station and reported that he was overdue.
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Police co-ordinated a sea and air search for three days, but found neither the deceased nor his boat.
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On 28 October 2016 residents of Grey, near Jurien Bay, found the deceased’s boat beached on the shoreline about three kilometres south of Grey. The deceased was not with his boat.
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An air and land search was then undertaken in the vicinity of the boat, but no sign of the deceased was found.
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On 25 November 2016 Mrs Doyle wrote to the State Coroner and requested that she investigate the deceased’s presumed death. The State Coroner wrote to Sergeant L J Stubbs at the Bunbury Police Station to request any information that could assist her to have reasonable cause to suspect that the deceased had died and that his death was a reportable death.
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Sergeant Stubbs responded to the State Coroner by letter, and on 8 August 2017 the State Coroner directed that the deceased’s suspected death be investigated.
Where the State Coroner has given such a direction, a coroner must hold an inquest into the circumstances of the suspected death of the person and, if the coroner finds that the death of the person has been established beyond all reasonable doubt, into how the death occurred and the cause of death.1 An inquest was therefore mandatory.
1 s23 Coroners Act 1996 Inquest into the suspected death of Jeffery Thomas Doyle 1489/2016
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On 11 July 2018, I held an inquest into the deceased’s suspected death at the Perth Coroner’s Court.
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The documentary evidence adduced at the inquest comprised a report, including attachments, compiled by Sergeant Stubbs.2 Sergeant Stubbs also provided oral evidence.3
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I have found that the death of the deceased has been proved beyond all reasonable doubt. I have found that the cause of his death is unknown but was probably immersion.
10. I have found that death occurred by way of misadventure.
TTHHEE DDEECCEEAASSEEDD
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The deceased was born on 24 May 1955, making him 61 years old at the time of his death. He was a crane driver, rigger and scaffolder and had worked predominantly in the South West region, particularly in the Collie area.4
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The deceased and his wife had been together since 1974 and they married in 1979. In 1980 they moved to the South West.5 They had one daughter, who in 2016 was a recently qualified medical doctor living in Queensland.6
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The deceased’s last employment was at a power station in Collie.7 He resigned from that job in September 2016 with the expectation to begin a new job a week later, but the new job fell through. He was upset at the time about being unemployed, but he was optimistic about finding work and kept himself busy at home and with his boat.8 2 Exhibit 1, Volumes 1 and 2 3 ts 3 – 20 per Stubbs, L J 4 Exhibit 1, Volume 1, Tab 3 5 Exhibit 1, Volume 1, Tab 5 6 Exhibit 1, Volume 1, Tab 3 7Exhibit 1, Volume 1, Tab 3 8 Exhibit 1, Volume 1, Tab 6 Inquest into the suspected death of Jeffery Thomas Doyle 1489/2016
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The deceased was relatively fit for his age and was in good general health. He had shoulder and knee problems from osteoarthritis, but he took antiinflammatories, was able to do most activities and was not limited in handling his boat effectively. In late May 2015 his doctor diagnosed him with mild depression and prescribed an antidepressant medication. He was back to normal within a month and was compliant with the medication.9
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The deceased was mechanically adept and was known as a Mr Fix-it among family, work colleagues and friends.
He did his own servicing and maintenance on his motor vehicles and boats, and he worked as a volunteer at the Binningup Surf Club as a maintenance/handyman in his free time.10
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The deceased had always been a keen fisherman, whether the fishing involved crabbing, netting or deep sea fishing.11 He had owned several boats of various sizes, and from 2007 he had a recreational skipper’s ticket. After relocating to the South West, he had regularly fished off the Bunbury coast. His favourite spot to catch dhufish was about 80 km from the coast.
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The deceased generally went fishing alone, including at night. He never used the Australian Coast Radio Monitors WA service (ACRM) to advise of his intended destination and expected time of return,12 but he would never overstay out at sea and would always let Mrs Doyle know when he was on his way back.13
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In June 2013 the deceased and Mrs Doyle bought a used Bertram 28 (the boat), which is a highly regarded 8.6 metre cabin cruiser with twin diesel engines.14 The deceased fitted it with the full complement of safety gear, including a working marine radio and two 9 Exhibit 1, Volume 1, Tab 5 and Volume 2, Tab 34 10 Exhibit 1, Volume 1, Tab 5 11 Exhibit 1, Volume 1, Tab 5 12 Exhibit 1, Volume 1, Tab 8 13 Exhibit 1, Volume 1, Tab 5 14 Exhibit 1, Volume 1, Tab 5 Inquest into the suspected death of Jeffery Thomas Doyle 1489/2016
emergency position indicating radio beacons (EPIRBs).
The boat was kept at a pen at the Bunbury Yacht Club where the deceased was a well-known and well-liked member.15
- In 2015 one of the engines on the boat broke down and required reconditioning. The engine was rebuilt in Perth and re-fitted after about 12 months. There was a timing problem with the new engine, but that was rectified a few weeks before the deceased’s death, and the deceased was happy with how the boat was running.16
EEVVEENNTTSS LLEEAADDIINNGG UUPP TTOO TTHHEE DDIISSAAPPPPEEAARRAANNCCEE
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On 16 October 2016 the deceased told Mrs Doyle that he was going to go fishing to take advantage of what he believed was a 24 hour extension of the demersal fishing season. He drove to the Bunbury Yacht Club and loaded supplies, including two cray pots, bait and ice, onto the boat.17 On the way there, he stopped at a bank machine and withdrew $150.18
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While still at the yacht club that evening, the deceased spoke to a committee member of the yacht club, Nicholaas Pronk, and told him that he intended to go out fishing and to drop his cray pots off Binningup. He said that he would have a drink and would then sleep until about 2.00 am the next morning, when the weather was expected to calm down. He would head out then.19
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The deceased headed out at daylight. As usual, he did not contact ACRM when he did so.20
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At 11.16 on 17 October 2016, Mrs Doyle sent the deceased a text message asking him whether he had gone out, given that the weather did not seem great. At 12.55 15 Exhibit 1, Volume 1, Tab 7 16 Exhibit 1, Volume 1, Tab 5 17 Exhibit 1, Volume 1, Tabs 5 and 7 18 Exhibit 1, Volume 1, Tab 5 19 Exhibit 1, Volume 1, Tab 7 20 Exhibit 1, Volume 1, Tab 8 Inquest into the suspected death of Jeffery Thomas Doyle 1489/2016
pm the deceased responded, ‘Alls gd no fish yet did not leave daylight battery low txt later xo’. Six minutes later, he added, ‘Weather just coming gd now woop!’21
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At about 3.30 pm that afternoon, Mr Pronk tried three times to call the deceased’s mobile phone to check that he was okay, but the calls went through to a message bank. On the last occasion, Mr Pronk left a message, and at 4.43 he received a missed call notice from the deceased’s phone but no message.22
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At 4.49 pm Mrs Doyle rang the deceased and spoke to him briefly. He told her that he went out ‘on 300’, meaning that he left on a bearing of 300 degrees from Bunbury harbour, and that it was windy so it would take him some time to get back. He said that his phone had only one bar of battery power, so they cut off the call.23
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At about 5.45 pm, Mr Pronk received a text message from the deceased saying, ‘G’day mate. All okay. Still out fishing. Will give you a call when I get back tonight’.24
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At 8.22 pm Mrs Doyle sent the deceased a text message asking if he had returned, but she did not receive a response.
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On 18 October 2016, Mrs Doyle did not hear from the deceased, but she had missed calls from the yacht club.
She went to the yacht club and spoke with some of the members who were worried about the deceased as he had not returned. She was not overly concerned at that stage, but went for a drive to see if she could spot the boat in the bay or at fisherman’s harbour, but she did not find him.25
- At 3.00 am on 19 October 2016 Mrs Doyle drove to the yacht club and saw that the deceased had still not returned. At just after 5.00 am that morning, she 21 Exhibit 1, Volume 1, Tabs 5 and 12 22 Exhibit 1, Volume 1, Tab 7 23 Exhibit 1, Volume 1, Tabs 4 and 5 24 Exhibit 1, Volume 1, Tab 7 25 Exhibit 1, Volume 1, Tab 5 Inquest into the suspected death of Jeffery Thomas Doyle 1489/2016
contacted the Bunbury Police station to report that he was overdue.
MMAARRIINNEE SSEEAARRCCHH
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A search for the deceased took place from 19 October 2016 until 21 October 2016 with the assistance of police officers at the Water Police Coordination Centre. Officers constructed a drift model to predict the likely direction and speed which a vessel or person would drift from a position identified from the deceased’s mobile phone’s last connection. Searches were conducted over approximately 8,500 square kilometres of ocean and 223 kilometres of coastline from 14 marine vessels, three helicopters, six fixed-wing aircraft, three ATVs and two four-wheel drive vehicles.26
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The search was suspended on the afternoon of 21 October 2016 because the boat was not on the surface of the water within the search areas covered and because the opinion of a recognised expert was that the time frame for the deceased’s survival if he had fallen overboard would have ended by the morning of 19 October 2016 at the latest.27
TTHHEE BBOOAATT IISS DDIISSCCOOVVEERREEDD
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On the afternoon of 28 October 2016, Paul Ganfield and his young sons, who lived in a shack at Grey about 45 kilometres south of Jurien Bay, were checking their cray pots in a dinghy off Grey when they spotted the boat on the beach. They returned to shore and drove to the boat in a four-wheel-drive vehicle.28
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The boat smelled terrible from rotting fish, and there was gear strewn over the deck, but the deceased was not on board. Mr Ganfield and his sons went home and, after 26 Exhibit 1, Volume 1, Tab 4 27 Exhibit 1, Volume 1, Tab 4 28 Exhibit 1, Volume 1, Tab 15 Inquest into the suspected death of Jeffery Thomas Doyle 1489/2016
Mr Ganfield unsuccessfully attempted to sell the story of finding the boat to a television station, they picked up two friends in Cervantes and drove back to the boat with an anchor and some rope. They arrived with about 30 minutes of daylight left. Their plan was to get the boat off the beach and anchor it out of harm’s way.29
- One of Mr Ganfield’s friends, Michael Hennessey, was an experienced deck hand in the fishing industry and was knowledgeable about boats. He noticed that there were keys in the two ignition switches and he checked the controls. The keys only activated the fuel gauge, which showed half a tank of fuel. The engines would not start.
The two throttle controls were both in neutral.30
- Mr Hennessey got off the boat and noticed that the right hand propeller had rope around it. He carried an anchor that was attached to the front of the boat with a chain and walked into the water until he was about neck deep.
A wave hit the boat, and the chain snapped and nearly hit his head. He dropped the anchor, and the men gave up on trying to save the boat.31
- Mr Ganfield and his sons and friends were driving back to Grey when they met up with police officers from Jurien Bay, whom they informed about the boat. They all then went to the boat and the officers declared it to be a protected forensic area.32
LLAANNDD SSEEAARRCCHH
- On 29 October 2016, police investigators began an examination of the boat as it sat on the beach. At the same time, an extensive air and land search was conducted by Western Australia Police, Department of Fire and Emergency Services and State Emergency 29 Exhibit 1, Volume 1, Tabs 15 and 16 30 Exhibit 1, Volume 1, Tab 16 31 Exhibit 1, Volume 1, Tab 16 32 Exhibit 1, Volume 1, Tab 21 Inquest into the suspected death of Jeffery Thomas Doyle 1489/2016
Services in the vicinity of the boat. No sign that the deceased had been in that area was found.33
EEXXAAMMIINNAATTIIOONN OOFF TTHHEE BBOOAATT
- The investigators examining the boat on the beach on 29 October 2016 soon determined that they could not continue the examination due to safety reasons related to surf crashing against the side of the boat.34 Arrangements were made to tow the boat to Jurien Bay behind a Fisheries Department vessel. The first tow rope affixed to the boat broke when an attempt was made to pull the boat off the beach. The tow rope later became entangled around the boat’s rudders and propellers.35
39. A second attempt to tow the boat was successful.
The Fisheries Department vessel towed it to the Jurien Bay marina where it was searched and examined.
The batteries were discharged and the fuel level was too low to power the engines when measured with the boat level.36
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The boat’s rudders, propellers and propeller-shafts were heavily fouled with significant amounts of different types of rope; namely, the white tow rope, a long length of black braided rope and some white synthetic rope.37
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The white synthetic rope was tightly bound onto the propeller-shafts, indicating that it had become entangled while the shafts and propellers were turning. It had tightened to the extent that the propeller-shafts had been forced upwards and had allowed the propellers to cut into the hull.38
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When removed, the white synthetic rope was found to be two separate lengths of rope. One length had a small eye 33 Exhibit 1, Volume 2, Tab 31 34 Exhibit 1, Volume 2, Tab 31 35 Exhibit 1, Volume 2, Tab 28 36 Exhibit 1, Volume 2, Tab 28 37 Exhibit 1, Volume 2, Tab 28 38 Exhibit 1, Volume 2, Tab 28 Inquest into the suspected death of Jeffery Thomas Doyle 1489/2016
tied in one end and the other end was tied to a steel fitting near hand-rails on the side of the boat. The other length was entirely bound around the propellers and rudders, and one end of it had a small frayed length of blue nylon webbing attached via a weighted metal swivel.39
- In the cabin of the boat, investigators found the deceased’s mobile phone, prescription medication, car keys and his wallet containing cash, identification and credit cards.40
FFUURRTTHHEERR IINNVVEESSTTIIGGAATTIIOONN
- As well as searching for the deceased, examining the boat and interviewing witnesses, police investigators carried out what was referred to in the inquest as proof of life searches, which involved seeking documentary evidence from government agencies, financial institutions and telephone service providers to indicate whether a person has had any contact or activity with any of them. There was no evidence indicating that the deceased had any such contact or activity.41
HHAASS TTHHEE DDEEAATTHH OOFF TTHHEE DDEECCEEAASSEEDD BBEEEENN EESSTTAABBLLIISSHHEEDD??
- On the basis of the foregoing, I find that the death of the deceased has been established beyond all reasonable doubt.
CCAAUUSSEE OOFF DDEEAATTHH AANNDD HHOOWW DDEEAATTHH OOCCCCUURRRREEDD
- The evidence does not allow me to find the cause of the deceased’s death with any degree of certainty.
39 Exhibit 1, Volume 2, Tab 28 40 Exhibit 1, Volume 2, Tabs 30B and 30C 41 Exhibit 1, Volume 1, Tab 2 Inquest into the suspected death of Jeffery Thomas Doyle 1489/2016
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Senior Investigations Officer Sue Matthews of the Department of Transport Marine Safety Unit worked alongside police investigators and conducted an independent investigation of the circumstances of the deceased’s disappearance. She noted that there was no evidence to suggest that the deceased had been injured while on board the boat, and that if he had fallen overboard, he should have been able to climb back on board from the platform at the stern.42
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Senior Investigations Officer Matthews concluded that the propellers may have become obstructed by the rope while the boat was off Bunbury and that, if the deceased had attempted to clear the propellers, he may have sustained an injury or had a medical issue and was not able to get back on board.43
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Sergeant Stubbs considered that the deceased was likely to have put the controls into neutral and to have gone into the water to investigate what had fouled the propellers. To do so, he would have had to dive under the stern of the boat, which would have been hazardous given that the waves and swell would have been causing the boat to thrash around.44 It is clear that a debilitating injury in those circumstances would have been possible and could have led to death by drowning, if not traumatic injury.
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It was also possible that the deceased became separated from the boat, that the wind caused the boat to drift away from him and that he could not swim fast enough to get back to it. The wind velocity and direction at 3.00 pm on 17 October was 17 km/h from the westsouthwest, but the maximum recorded wind gust that day was 33 km/h from the south.45
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It was also possible, though perhaps less likely, that the deceased was taken by a marine predator.46 42 Exhibit 1, Volume 2, Tab 32 43 Exhibit 1, Volume 2, Tab 32 44 ts 14 per Stubbs, L J 45 Exhibit 1, Volume 1, Tab 9 46 ts 14 and 15 per Stubbs, L J Inquest into the suspected death of Jeffery Thomas Doyle 1489/2016
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Given those possibilities, I am unable to find a cause of death, but it does appear that immersion (drowning) was the most probable.
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While I am unable to find the cause of death, I am satisfied that the deceased had entered the water to investigate or to attempt to remove the ropes around the rudders, propeller-shafts and propellers, and then died from an unascertained cause. There is no evidence to suggest that he would have died had he not entered the water.
54. I find that death occurred by way of misadventure.
CCOONNCCLLUUSSIIOONN
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The deceased died at sea doing what he loved, but his death was easily preventable. He was a knowledgeable and experienced recreational skipper and fisherman in a seaworthy boat that was equipped with extensive safety gear, including a marine radio and EPIRBs. He also had a mobile telephone with some battery power and was probably in range of a mobile tower range at the time the boat was disabled by ropes fouling the propellers.47
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Sergeant Stubbs noted that, because the deceased was alone, he had no option other than to investigate the problem himself if he was to attempt to rectify it.48 Sergeant Stubbs also noted that the deceased was wellknown as a Mr Fix-it, so he would probably have been inclined to make that attempt.49 In the likely sea conditions at the time, any such attempt would have been risky at best.50
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It is also possible that the deceased partly fouled the propellers with his own cray-trap rope, which may have provided further incentive to fix the problem himself.
47 Exhibit 1, Volume 1, Tab 2 48 Exhibit 1, Volume 1, Tab 2 49 ts 18 per Stubbs, L J 50 ts 14 per Stubbs, L J Inquest into the suspected death of Jeffery Thomas Doyle 1489/2016
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In the objectivity of hindsight, it is clear that the deceased should have used his radio or phone, or activated an EPIRB, in order to seek assistance.
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The deceased’s untimely death provides a reminder for all recreational boat users that, while it may be embarrassing to call for rescue, the alternative could be fatal, even for competent skippers. Marine rescuers do not charge to tow vessels to shore,51 and they would much prefer to tow a stranded boat than to search in vain for missing boaters.
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At the very least, boat users should make use of the ACRM to assist in ensuring that, if they do not return at the expected times, searches are conducted without delay to increase the likelihood of success. Yacht clubs would be well-placed to encourage their members to do so.
B P King Coroner 17 August 2018 51 ts 19 per Stubbs, L J Inquest into the suspected death of Jeffery Thomas Doyle 1489/2016