Inquest into the 4 Deaths at Mount Augustus

[2022] WACOR 29 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : Sarah Helen Linton, Deputy State Coroner

DELIVERED : 17 JUNE 2022 FILE NO/S : CORC 26 of 2019

DECEASED : BUSKE, HANS-JUERGEN FRIEDRICH FILE NO/S : CORC 25 of 2020

DECEASED : POLLARD, ANNE MAREE FILE NO/S : CORC 26 of 2020

DECEASED : GREEN, BRIAN PATRICK FILE NO/S : CORC 27 of 2020

DECEASED : GREEN, THELMA JACINTA Catchwords: Nil Legislation: Nil Counsel Appearing: Ms R Collins assisted the Deputy State Coroner.

Mr J T Bishop and Ms A Seen (State Solicitor’s Office) appeared for the Department of Biodiversity, Conservation and Attractions, Western Australia Police Force, Department of Fire and Emergency Services and the Western Australian Country Health Service.

Mr G Janssen and Ms Sasirekha appeared for the family of Mr Buske.

Case(s) referred to in decision(s): Nil

[2022] WACOR 29 Coroners Act 1996 (Section 26(1))

RECORD OF INVESTIGATION INTO DEATH I, Sarah Helen Linton, Deputy State Coroner, having investigated the deaths of Hans-Juergen Friedrich BUSKE, Anne Maree POLLARD, Brian Patrick GREEN and Thelma Jacinta GREEN with an inquest held at the Perth Coroner’s Court, Court 85, CLC Building, 501 Hay Street, Perth from 23 to 26 November 2021, find that:

1. The identity of the deceased person found on 11 November 2019 was HansJuergen Friedrich BUSKE and that death occurred on or about 9 November 2019 at Mount Augustus National Park as a result of atherosclerotic heart disease in a man with environmental exposure;

2. The identity of the deceased person found on 14 September 2020 was Anne Maree POLLARD and that death occurred on 14 September 2020 at Mount August National Park as a result of heat stroke (environmental exposure);

3. The identity of the first deceased person found on 16 September 2020 was Brian Patrick GREEN and that death occurred on 15 September 2020 at Mount August National Park as a result of heat stroke (environmental exposure);

4. The identity of the second deceased person found on 16 September 2020 was Thelma Jacinta GREEN and that death occurred on 15 September 2020 at Mount August National Park as a result of heat stroke (environmental exposure); and their deaths occurred in the following circumstances:

[2022] WACOR 29 Table of Contents 9 – St John’s Ambulance provide a first aid room at the Tourist Park and provide first 14 – Investigate the viability of a rescue helicopter based in the mid-west with 15 – Burringurrah MFPS to be manned at all times to provide an emergency response .. 118

[2022] WACOR 29 INTRODUCTION

1. This was a joint inquest held in relation to the deaths of four people: Hans-Juergen Friedrich Buske, Ann Maree (usually known as Maree) Pollard, Brian Patrick Green and Thelma Jacinta Green. All four died whilst hiking the Summit Trail on Mount Augustus, known to the traditional owners as Burringurrah, in the heart of the Gascoyne Region of Western Australia. Mr Buske died in November 2019 and Mrs Pollard and Mr and Mrs Green died within two days of each other in September

2. They were not the first deaths to occur on Mount Augustus, but I understand they are the first deaths to be investigated by way of inquest in this Court.

3. Mr Buske was a visitor to Western Australia from Germany and was travelling around the State with his wife. Mr and Mrs Green and Mrs Pollard were all Perth residents who were visiting Mount Augustus while on holiday within their own State.

They were all experienced travellers and Mrs Pollard, Mr Green and Mrs Green were also experienced hikers. Although all were older than 50 years of age (with Mr Buske, Mr Green and Mrs Green considerably older than that) they all considered themselves to be generally fit and healthy for their age. Nevertheless, all four people found themselves in extremis when walking up Mount Augustus in the heat of the day. The temperatures at the time of their deaths reached well above 37° Celsius in each case, even though it was not yet the full height of summer, and all four people succumbed to hyperthermia in the sweltering conditions.

3. Mount Augustus is in a remote part of Western Australia, with limited communications available to raise the alarm when things go wrong, and small chance of immediate help being nearby unless someone happens past at the right moment. It is also a long way for any coordinated emergency response to be mounted when the alarm has been raised. The same can be said for much of regional Western Australia, but Mount Augustus is an increasingly popular tourist site, which makes it more concerning. The remoteness of the location caused particular difficulties for the emergency responders in relation to these deaths.

4. Inspector Darryl Cox was attached to the Mid-West Gascoyne District Office at the relevant times in 2019 and 2020 and was involved in the emergency response in these cases. Inspector Cox was the Police Commander for the search for Mr Buske and the Police Forward Commander for the searches for Mr and Mrs Green, as well as for the search for another lady who is mentioned later, who went missing but was fortunately found alive. Inspector Cox prepared a comprehensive report for the coroner, setting out the circumstances of each unexpected death, identifying the safety issues the deaths highlighted and suggesting a series of recommendations that might be made following the coronial inquiry to reduce the risk of further deaths on Mount Augustus.

5. Based upon the information provided in Inspector Cox’s report, I made a direction under s 24 of the Coroners Act 1996 (WA) that it was desirable to hold an inquest into each death to consider the causal factors that led to the deaths and how these deaths point to issues related to public health and safety for other visitors to Mount Augustus in the future.1 Pursuant to s 40 of the Coroners Act the State Coroner 1 Section 24 Coroners Act 1996 Direction of Deputy State Coroner dated 17 December 2020.

[2022] WACOR 29 directed that the deaths be investigated at one inquest, given the similarities in the circumstances of their deaths and the common issues to be considered.2

6. I directed that the inquest be held in Perth as many of the family and friends who were able to attend in person were based in Perth, and many of the key witnesses were also based in Perth by the time of the inquest hearing. Those witnesses who could not be in Perth were heard by videolink or telephone link, and a limited number of family members were able to livestream the proceedings from outside the State.

7. Prior to the commencement of the inquest, together with counsel, I also met personally in an informal setting with Mr Charles Snowball. Mr Snowball is the Chairperson of the Burringurrah Aboriginal Community and a senior elder within the community of Burringurrah with cultural authority to speak for the traditional custodians of Burringurrah (Mount Augustus). This meeting was conducted in order to seek Mr Snowball’s views on the issues arising in this inquest and how the traditional custodians wish this sacred site to be managed in light of the recent deaths. Mr Snowball was not available to give evidence at the time of the inquest, so this was an opportunity to consult with him in advance. With the permission of Mr Snowball and others, Mr Dwayne Mallard, the current chairperson of the Wajarri Yamatji Corporation that includes Burringurrah, also gave evidence at the inquest to formally offer condolences from the Wajarri community to the families of the deceased and to give evidence about the aspirations of the Wajarri community for Burringurrah in the future. It was clear that these deaths have cultural implications for the traditional custodians and they are committed to working with the other stakeholders to try to ensure that further deaths are prevented, while also encouraging visitors to come to appreciate the natural and cultural significance of this place for the Wajarri Peoples.

MOUNT AUGUSTUS (BURRINGURRAH)

8. The Wajarri Peoples are the traditional custodians of approximately 45,000 hectares of land in the Gascoyne region. Mount Augustus and its surrounds are part of the traditional lands of the Wajarri Peoples. Burringurrah is the Wajarri name for Mount Augustus, and in its longer form is known as “Burringurrah, the boy who was speared due to cultural reasons’. Burringurrah was said to be a young boy that fled law business in the east and ran to the west. He was pursed by the old lawmen who found him there and speared him and clubbed him to death, and the rock formation is where Burringurrah now lays. That is why the area is sacred to the Wajarri people.

Visitors to the area can view Aboriginal rock engravings from thousands of years ago, an example of the long historical significance of the area for the Wajarri people.

Other sacred areas are protected from the general public.3

9. Mount Augustus itself is an ‘inselberg’, meaning ‘island mountain’, or monocline. It rises 715 metres out of the surrounding alluvial plain and is about 8 kilometres long.

The vegetation is predominantly arid shrubland and there is a variety of wildlife to be found, including many native birds, goannas and kangaroos.4 Mount Augustus is 2 Section 40 Coroners Act 1996 Direction of State Coroner dated 17 December 2020.

3 Exhibit 1, Tab 1 and Tab 18; Exhibit 3, Tab 10.

4 Exhibit 1, Tab 18.

[2022] WACOR 29 contained within the Mount Augustus National Park. No one lives in the national park and no camping is allowed. The closest place to stay is the Mount Augustus Outback Tourist Park (Tourist Park), a privately operated business on the edge of the national park. The nearest larger towns are Carnarvon (465 kilometres) and Meekatharra (345 kilometres) and access to Mount Augustus is via unsealed (gravel) roads. Perth is 852 kilometres away.5

10. Located about 70 kilometres from Mount Augustus is the Burringurrah Aboriginal Community, with a fluctuating population of around 200 people. This is where many of the local Wajarri people live who regularly visit and care for Mount Augustus. Mr Snowball, who I have mentioned above, is employed as an Indigenous Park Ranger by the Yamatji Aboriginal Corporation. He is now the boss of four paid trainee rangers, all local men from the Burringurrah Community and relatives of Mr Snowball, who are employed by the Department of Biodiversity, Conservation and Attractions (DBCA) to care for the land, native flora and fauna and culturally significant sites.6 Together, they liaise with tourists at Mount Augustus and assist people to keep on the tracks and ensure that they do not go into any sacred areas. I note the four trainee rangers, separate from Mr Snowball, have only recently been employed in that role, and they were not employed by DBCA at the time of the deaths the subject of this inquest.7

11. Mr Snowball indicated that he goes to Mount Augustus every day, usually starting at the Tourist Park and talking to the tourists who are there, before setting off to the hill and checking all of the sites around it. Mr Snowball indicated that there is more consultation with the indigenous rangers since the deaths the subject of this inquest, and he thinks that has led to improved signage for the walking trails.8

12. Mr Snowball said that he wouldn’t walk up to the summit himself in the summer time, because it is very hot then. He described this period as October to Christmas time. When Mr Snowball does go up to the summit, he said that he usually leaves at around 5.00 or 6.00 am, before it is light. He noted that it is harder coming down than going up, as the rocks are slippery and you have to go slower. Mr Snowball estimated it might take him a total of 12 hours to go to the top of the summit and back again, but noted he is usually checking things along the way. If he comes across tourists, Mr Snowball said he will speak to them and explain that the descent can be worse than the climb up, but he won’t always see them as many people will have left before he arrives.9

13. Mr Snowball told police that he does not think it is very safe to walk up Mount Augustus when the temperature gets close to 30°C unless the person is very fit and has a lot of water. He indicated that the rangers would not walk up in a month such as November, as it is far too hot to go up there then.10 5 Exhibit 1, Tab 1 and Tab 18.

6 T 5.

7 Exhibit 3, Tab 10.

8 T 5 – 6, 24.

9 T 8 – 9.

10 Exhibit 3, Tab 3 [35].

[2022] WACOR 29

14. Also located at the Burringurrah Community is the Burringurrah Multi-Functional Police Facility (Burringurrah MFPF), which is staffed with two police officers.11 Further, there is also a Nursing Post at the Community resourced and staffed by the WA Country Health Service (WACHS), and it is therefore part of the public health system. The nursing post is staffed by two nurses and they are primarily employed to provide health services to the Burringurrah Aboriginal Community.

15. Mount Augustus National park is managed by the DBCA, which incorporates the former Department of Parks and Wildlife, who have the primary responsibility for managing the State’s national parks, including Mount Augustus.12 For simplicity’s sake, I propose to refer to them as DBCA in this finding. At the time of these deaths, the nearest DBCA office in Carnarvon had closed and the closest DBCA office is now in Denham (the Shark Bay District), which is approximately an eight hour drive from Mount Augustus. DBCA staff would attend Mount Augustus intermittently, primarily in the high season.13 The DBCA mission, in relation to Mount Augustus as part of a national park, is to “conserve biodiversity and wildlife, provide sustainable recreation and tourism opportunities, protect communities and assets from bushfire”14 and other management perspectives that fit within that framework.15

16. Loop Drive, a 49 kilometre road that circles Mount Augustus National Park, provides access to a number of different walking trails, including the climb to the summit.

There are 11 trails in total. All the trails in the park are essentially unmodified tracks, very rocky and with only basic marking. Walkers are encouraged to wear sturdy footwear and protective clothing and to take particular note of the difficulty rating of each walk, as the trails are graded in difficulty according to the Australian Standards for Walking Tracks. All of the walks are at least a Class 3, requiring a moderate level of fitness. It is not uncommon for walkers to sometimes lose their way on the trails, and it is very hard for people to find their way back in those circumstances, which also means that it is more suitable for people with a reasonable level of bushwalking experience.16

17. The Summit Trail walk is approximately six kilometres from the carpark to the summit (so a 12 kilometre return trek). It takes walkers to a level 650 metres above the carpark. The walk is divided into sections marked by different gradients and there are two trails for the lower part of it, being the Gully Trail and the Summit Trail. At the time these deaths occurred, the difficulty rating of the Summit Trail was rated a Class 4 (a moderate to high level of fitness is required - users should be prepared and self-reliant) and the Gully Trail was a Class 5 (A high level of fitness is required - users must be prepared and self-reliant). A Class 5 is generally the highest rating given to hiking tracks in Australia. There is a Class 6, which is effectively not a trail but is rather described as a “wilderness experience.”17 It is noted for both the Class 4 and Class 5 trail classifications that weather can affect the safety of the walk. The 11 Exhibit 1, Tab 1, p. 15.

12 Exhibit 3, Tab 16, p. 5.

13 Exhibit 1, Tab 1, p. 9; Exhibit 3, Tab 3.

14 Exhibit 3, Tab 16, p.4.

15 Exhibit 3, Tab 16, p. 33.

16 T 17; Exhibit 1, Tab 18; Exhibit 3, Tab 16, p. 36.

17 T 370.

[2022] WACOR 29 general park information suggests the Summit Walk is a difficult walk and should only be undertaken by prepared and experienced bushwalkers.18

18. There is no drinking water in the park and only basic picnic facilities and compost toilets services. There are some natural watercourses present at certain times of the year, but even when water is available at a natural water source it needs to be treated before it is safe for human consumption. Walkers are, therefore, encouraged to always carry enough water for their own needs. The park information guide suggests walkers should carry and drink 3-4 litres per person per day. It is noted that heat stroke can kill and summer temperatures are extremely hot.19 There is no weather station at Mount Augustus, with the nearest weather station at Karajini National park, Murchison, Paraburdoo, Meekatharra and Newman. The closest of these is Paraburdoo, so temperatures are generally taken from there, but it is considered that the temperatures at Mount Augustus, particularly on the summit trail, will generally be significantly higher, at least during the day, due to the heat emanating from the rock surface.20

19. The general information available suggests it takes as little as five and as much as eight hours to complete the walk, with DBCA signage suggesting the general estimate is about six hours. However, there was also evidence given that it often takes longer than visitors expect and is harder and slower on the way down, due to the slippery rocks, the heat and the fact that the hikers are becoming tired on the descent. Therefore, there was a suggestion in the evidence that these estimates should possibly be revised and increased.

Exhibit 1, Tab 18 – Mount Augustus National Park, Burringurrah Trail Map 18 Exhibit 1, Tab 18.

19 Exhibit 1, Tab 18.

20 Exhibit 1, Tab 1, p. 35.

[2022] WACOR 29

20. There was evidence at the inquest that, in the past, Mount Augustus was not an especially busy tourist destination. However, in recent years the level of interest and visitors has increased significantly. Some of this increase is attributed to more Western Australians taking holidays within Western Australia due to the COVID 19 border closures, with the State Government encouraging locals through Tourism Western Australia to “wander out yonder”21 in their own backyard. Mount Augustus is also being promoted by some as the ‘largest rock in the world’ (although as noted above it is technically not a rock) and since the closure of Uluru to walkers, it is believed there has been an increase in interest from interstate and international visitors in visiting, and specifically climbing, Mount Augustus for that reason.22 One witness described the thought process of many people who wish to walk to the summit as being: “They want to conquer. They want to explore. They want to get there. That’s what they come for, in general.”23 DBCA’s role is to balance the demands for access and enjoyment of the lands with the requirement for visitor safety. DBCA staff acknowledged that the recent levels of visitation at Mount Augustus are unprecedented, and with increased numbers comes increased risk.

During the 2020/21 financial year, visitation to Mt August was estimated to have increased by 55% (based on a previous average of 4,000 visitors in the high season and much less throughout the rest of the year).24 However, at this stage it is difficult to predict whether the numbers will stay high now that people are able to travel interstate and internationally again.25

21. Superintendent Roger Beer, who is the District Superintendent for the very large Mid-West Gascoyne District, which runs from Jurien Bay in the south up to almost Coral Bay in the north and then inland, including Mount Augustus, gave evidence his officers have definitely noticed an increased volume of travellers since COVID, which has created some serious safety issues for unprepared travellers around the State.26 The CEO of the local shire also gave evidence that they have had issues with inexperienced tourists coming into difficulty in many of the remote areas in the Gascoyne, not only Mount Augustus. Therefore, the issue is not unique to Mount Augustus, but given the number of deaths that have occurred on Mount Augustus, it requires a more specific focus.27

22. The Tourist Park is owned by Mr Donald (Don) Hammarquist, who also owns Mount Augustus Station on which the Tourist Park is located. The Tourist Park has been running since the mid 1980’s. Mr Hammarquist and his family run the station with the assistance of some staff. and Mr Hammarquist has a manager in place to run the Tourist Park. Mr Hammarquist is an active member of the local Shire of Upper Gascoyne and has served as the Shire President for the last three years or so. In his private enterprise, and through his role with the Shire, Mr Hammarquist has had a long involvement in trying to improve facilities for tourists in the Mount Augustus area. He was awarded the Order of Australia Medal in 2019 for his services to the community in the Shire of Upper Gascoyne.28 21 Wander out Yonder in WA - Tourism Western Australia.

22 Exhibit 1, Tab 1, p. 10.

23 T 290.

24 Exhibit 3, Tab 16, p. 35.

25 T 337; Exhibit 3, Tab 6, pp. 5 - 6.

26 T 153.

27 T 220 – 221.

28 Exhibit 3, Tab 11.

[2022] WACOR 29

23. Mr Snowball also indicated that his father knew Mr Hammarquist Senior, and he now works with Mr Hammarquist’s son and their working relationship is good.29 Similarly, Mr Hammarquist referred to his relationship with Mr Snowball and Mr Snowball’s father as, in effect, a good working relationship with mutual respect on both sides.

24. Mr Hammarquist indicated in his statement the main reason tourists visit the area, and stay at the Tourist Park, is to walk or hike to the summit of Mount Augustus.

However, he also agreed that some tourists came just to experience the outback and “definitely not everyone wants to climb it.”30 Like other witnesses, he confirmed there has been a recent rise of tourism visitors to the station. Mr Hammarquist indicated that the visitation numbers for 2020 were approximately 20,000 people. All of the deceased were staying at the Tourist Park at the time of their deaths and staff from the Tourist Park were involved in aspects of the search and recovery operations for each of them. Mr Hammarquist was only personally involved in Mr Buske’s search as he was not at Mount Augustus in September 2020. Mr Hammarquist’s son, David, was also involved in the search for Mr Buske and possibly some of the others.31

25. The Hammarquist family obviously have an interest in what changes, if any, are made at Mount Augustus, given their business interests in the area. However, they also have a personal interest as they are some of the first responders to many of these incidents, which has informed their understanding of how and why people have come into difficulty. From his experience, Mr Hammarquist believes a contributing factor in most of the incidents where people have got into difficulties is “due to them not adhering to the advice given,”32 which includes ensuring they have enough water, commencing the hike early to avoid high temperatures and wearing a hat and sunscreen.

26. The Mount Augustus Station/Tourist Park is not responsible for the running of the Mount Augustus National Park, as that role falls to DBCA, but given its proximity and the fact that most of their guests intend to visit the park, the Tourist Park staff do provide some advice to guests in this regard. The visitors can also collect DBCA information pamphlets on the park at the Tourist Park shop/office and the staff also take it upon themselves to emphasise the need for taking enough drinking water etc.

27. At the time of these deaths, the Tourist Park also facilitated a procedure of a visitor ‘sign-in book’ in the Tourist Park shop/office. Visitors who intended to walk the Summit Trail were encouraged to sign their name, car registration and the time of their departure for walking on Mount Augustus in the book, and then they were asked to then sign back in when they returned safely. Mr Hammarquist indicated the visitor book has been in use for about 10 years. He believed it was initially set up by DBCA and then the Tourist Park took it over, although the DBCA staff have indicated this is not their understanding and they do not believe DBCA have ever had

29 T 18.

30 T 274.

31 Exhibit 3, Tab 11.

32 Exhibit 3, Tab 11 [38].

[2022] WACOR 29 input into the visitor book system.33 An issue with the visitor book was that it was not actively monitored, so if someone did not return and sign back in, it was entirely possible no action would be taken to initiate a search. The Greens are an example of this and their family expressed their belief that their parents would have taken false reassurance from making an entry in the book. Mr and Mrs Green’s family believe their parents would have had an expectation that someone would come looking for them if they did not return within a reasonable time period.34 This did not, however, occur.

DIFFICULTIES MOUNTING AN EMERGENCY RESPONSE

28. Inspector Cox identified a number of challenges in relation to the searches undertaken at Mount Augustus for the people the subject of this inquest. They included:35

• The remoteness of the search area;

• Limited police in proximity to the search area;

• Limited communication on Mount Augustus;

• Extreme temperatures on the mountain;

• No immediate access to SES volunteers;

• Unsafe conditions to search at night on foot;

• Limited ability to do aerial searching at night given that thermal imaging cameras on the Joint Response Coordination Centre (JRCC) plane were ineffective on the hot rock surface of Mount Augustus;36 and

• Limited medical response capability in the even that a person was located alive but injured or otherwise in need of medical treatment.

29. The WA Police are the hazard management agency for land search and rescues (known as LandSAR) in Western Australia, although many other organisations and government agencies are also involved. The Police Emergency Operations Unit oversee all land searches in Western Australia, but it is the local police who provide the initial response. The problem with Mount Augustus is the remote location means that the local police presence is very limited. As noted above, there are two police officers stationed at the Burringurrah MFPF, which I’m told is anything from a 20 to 40 minute drive from Mount Augustus. The next nearest officers are based in Meekatharra, which is at least a four hour drive away, depending on road conditions.

From there, the staff at Carnarvon Police Station are the next closest, being a five to six hour drive away. Officers can also be drawn from Geraldton, Mt Magnet, Cue and further afield. Flights are limited at night, so driving is often the only option. The incident is usually managed from Geraldton, with the Police Commander and other staff located at the Geraldton Command Centre. A Police Forward Commander is then usually sent to the scene in order to feed relevant information back through the chain and make some decisions on the ground.37 33 T 260; Exhibit 3, Tab 11.

34 T 289; Letter from Family to the Court - dated 2 December 2021 35 Exhibit 1, Tab 1.

36 T 23 - 24.

37 T 22 - 23.

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30. WA Police Emergency Operations will submit a written request for DFES and SES assistance to the DFES State Operations Centre. The request is then forwarded to the appropriate DFES Regional Duty Co-ordinator, which for Mount Augustus is Mr Brendan Wilson, who is based in Geraldton. Mr Wilson has undertaken that Regional Duty Co-ordinator role for a number of the recent searches at Mount Augustus and has coordinated the arranging, deployment and management of SES volunteers for the searches and appointing a DFES Commander to go to the scene of the search.

DFES are reliant on the availability of the SES volunteers in order to adequately respond. Due to the remoteness and location of Mount Augustus, there are logistical challenges in deploying DFES staff, equipment and SES volunteers to Mount Augustus. There are no SES volunteers based at Mount Augustus or at the nearby Burringurrah community, so the SES volunteers are based in areas much further afield, including Geraldton, Meekatharra, Kalbarri, Shark Bay, Carnarvon, Eneabba and Moora. They can also be drawn from Karratha if there are no sufficient people available from those areas. One of the challenges is simply getting these volunteers from where they live to Mount Augustus. It is also relevant to note that these are local people who live and work in the regional communities, so they have work and family commitments which affects their availability at any given time, and also means they may require some time to organise themselves before they can start the journey, which will inevitably be a long one given the locations the volunteers are drawn from.38

31. Mr Wilson gave evidence that there has never been a case that they have not been able to deploy volunteers to Mount Augustus, but the strength of the contingent they can send depends upon how much notice they are given and the timing of when it is received.39

32. Mr Wilson gave evidence that the preference is to fly volunteers from their homes to Mount Augustus, given it is a 90 minute light aircraft flight as compared to an 8-10 hour journey in a road vehicle. A short flight means both that they get the volunteers to the site sooner. If they are required to complete the long drive, they will already be fatigued before they even start the search, which raises welfare issues and may mean that they will require a rest period before they can start to participate in the search.40

33. Inspector Cox explained at the inquest that they can’t fly in SES staff from Geraldton at night, as charter flights can’t fly at night, so they often have to start with Meekatharra SES volunteers, who can complete the shorter drive. In some instance they may only have one or two volunteers available in Meekatharra, and the age and abilities of these volunteers is also relevant. In at least one case, the only available SES volunteer from Meekatharra was a man in his late sixties, who obviously could not be asked to walk the mountain, although his services were able to be utilised as a spotter in a plane. Therefore, searching by SES volunteers will often have to be delayed until daylight, when they can be flown in from Geraldton or even Perth.

Even then, there is a need for young and fit searchers at Mount Augustus for the ‘on foot’ part of the searching, as it is an arduous and physically demanding task and DFES is very conscious of protecting the safety and welfare of their volunteers.41 38 T 167 - 168; Exhibit 3, Tab 2.

39 T 175.

40 T 168 – 169.

41 T 23, 28, 168.

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34. Inspector Cox also commented that even for the police, there is a focus on trying to get the fitter officers to go up the mountain, particularly in the case of the recovery operation for Mr and Mrs Green, where the police officers had to go up and recover bodies twice in two days. Inspector Cox advised that the police considered flying the TRG up from Perth to provide assistance, but in the end they concluded that the delay would be too great, so they simply did the best they could with the police officers available.42

35. Interestingly, although DBCA is responsible for management of the attraction, they generally have not, in the past, had a designated role in the search. Superintendent Beer, who is the District Superintendent of the Mid-West Gascoyne District, gave evidence that after the death of Mr Buske, it was identified in the emergency response debrief that it would be helpful if DBCA staff could be represented in the Police Command in Geraldton, as well as supporting the Forward Command at Mount Augustus, where possible. Superintendent Beer indicated that the DBCA did provide that support in the later searches and recovery operations for Mrs Pollard, Mrs Ansell and the Greens,43 although it would seem this was Geraldton DBCA staff rather than the Shark Bay Office staff who have specific responsibility for Mount Augustus.

36. There has also been a change in the sense of having DBCA-employed rangers based at Burringurrah Community, working with Mr Snowball, which has improved the involvement of DBCA in local searches. Mr Snowball indicated that he has always been involved in all the searches, and indeed he was responsible for finding Mrs Ansell.44

37. At the inquest, Inspector Cox explained that not only is it time-consuming to get searchers to the area, often if they have driven there, they will need time to rest after the long drive before they can begin searching. There is also the difficulties in getting the appropriate equipment to the location, not only to feed and shelter the searchers, but also to run the search. This is all in the context that time is of the essence when searching for a missing person at Mount Augustus, given the heat and harshness of the environment, which usually means they often have only hours to be saved, rather than days. As Inspector Cox noted, the police will always get resources to an area to conduct a proper search and rescue, but it takes time to get those resources to a remote area like Mount Augustus.45

38. As noted in the summary, one tool often used to search quickly for a missing person lost in the bush at night is the Joint Rescue Coordination Centre (JRCC) plane, which is equipped with thermal imaging, but the rock gives out too much heat to make it an effective tool. Inspector Cox explained that the JRCC plane was used on the night of 9 November 2019 and morning of 10 November 2019, when Mr Buske went missing, but it could not assist in locating Mr Buske.46

42 T 34.

43 T 145 - 146.

44 T 48 – 49.

45 T 24, 28 - 29.

46 T 23 – 24.

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39. A local helicopter has also been used to facilitate searching, but it does not have the ability to winch someone off the mountain if they are found, and no other helicopters in the local area have the capacity. Neither does the Police Air Wing helicopter have that capacity.47 This is important when considering the difficulties in trying to get either an injured person, or a body, off the mountain. Inspector Cox gave evidence that one of the biggest challenges he faced during all of these incidents was having to make the decision to leave Mrs Green’s body on the trail overnight. They did not have the ability to return up the trail and recover her safely after recovering Mr Green’s body and bringing him down to the carpark at 6.00 pm when it was getting dark. Inspector Cox described it as a “very, very difficult decision to leave someone on the mountain”48 and if they could have had a helicopter to winch her body off, they would have used it, but there was no such resource available.

40. Inspector Cox, who personally walked up to retrieve Mrs Green’s body, noted that on the part of the trail that he did, it was extremely hot due to the heat coming both from the air and the rock, which was very different to the ordinary heat when walking in the bush. He also noted that the water he was carrying heated up and made it difficult to drink. There were a lot of flies and it was very hard work. The markers required some attention to find and Inspector Cox lost the trail at one stage and had to retrace his steps. On the descent, the police officers had the added difficulty of carrying bodies on stretchers, and they found it was not easy walking down and often lost their footing on the rocks 49

41. Communication has been a major issue at Mount Augustus, and was a primary focus of the inquest. Inspector Cox spoke about the problems with mobile phone coverage at Mount Augustus, both at the Tourist Park and on the climb to the summit. At the time of these events, there was only Optus coverage at the Tourist Park, so the police and government phones that used Telstra did not work. Even the satellite phone coverage was intermittent, which hampered the ability for searchers to communicate with each other and with the Police Commander and other members of the Incident Management Team in Geraldton. The issue of communication coverage was also relevant to the deaths themselves, as there was evidence that there was no coverage on the summit trail, and only limited mobile coverage on the summit. Therefore, when people got into trouble, there was no way of calling for help.50

42. DFES has an incident control vehicle that can be deployed to the scene and provide significantly better communications as it can broadcast its own radio network, but it takes the best part of 10 to 11 hours to get the vehicle there, which again means a significant time delay.51

43. The other main area of concern raised by Inspector Cox was the difficulty that if they did locate a person who required medical assistance, the understanding of the police was that there was no immediate medical help available. There is a first aid post at Burringurrah, manned by a nurse, but they were generally not allowed to leave the community to go to Mount Augustus to provide help at that time, and the nursing staff did not have access to an ambulance nor the ability to provide critical care. The

47 T 26 – 27.

48 T 31.

49 T 18, 21, 31.

50 T 27, 169.

51 T 169.

[2022] WACOR 29 closest St John Ambulance service is in Meekatharra and it is manned by volunteers who generally are not in a position to travel the long distance to Mount Augustus.

The Royal Flying Doctor Service (RFDS) has limited capacity to land at Mount Augustus at night, and will only come once a patient is found who requires urgent medical care.5253

44. Mr Justin Fonte, who is the Head of Country Operations for St John’s Ambulance in Western Australia (SJA), confirmed at the inquest that there is no ambulance service operation directly at Mount Augustus, with the closest SJA operation being at Meekatharra, and the next at Carnarvon. Both areas are staffed by a volunteer workforce, so the SJA contract with the State Government for those locations is to the standard of their “best endeavours” to deliver services, rather than a guaranteed or assured ambulance service. Mr Fonte indicated that both the Meekatharra and Carnarvon volunteers are able to service their local communities well, but acknowledged that providing an emergency response, or even transfer service, to Mount Augustus is difficult given the distances involved and the fact that it would then leave those local areas at risk of having no one available to provide an emergency response in the interim. Mr Fonte did indicate that the State Operations Centre will still monitor triple zero calls and SJA will speak to the volunteers to see if they can assist, and if not, they can then try to orchestrate other services to assist such as engaging RFDS or requesting local police assistance. Needless to say, these options don’t provide much reassurance to Inspector Cox and the other police officers providing the emergency response.54

45. However, Mr Fonte did indicate that SJA have the ability to deploy urban search and rescue paramedics from Perth to any location, including Mount Augustus, at the request of police. They will often be utilised to set up first aid posts for the search teams, rather than specifically being there to provide first aid to any missing person found, but obviously can provide emergency care to a person who requires it.

However, sending such a resource has the same time delay issues as sending more police or SES searchers, with Mr Fonte noting it will usually take at least 24 hours to get them to Mount Augustus. Nevertheless, it is a worthwhile option to explore if it appears the search is likely to be of some duration, noting that the risks of dehydration and injury for the searchers is likely to be high.55

46. Acting Superintendent Stephen Scott, who is currently the Divisional Officer for emergency management and specialist support, which includes the WA Police Emergency Operations Unit, gave evidence at the inquest about the functions of the Emergency Operations Unit (EOU). He explained the EOU contributes to search and rescue operations by providing strategic oversight, as well as training police officers across the State to be search mission controllers.56 The other role of the EOU is to liaise with partners, such as DFES if they are going to request assistance from SES volunteers.57 A/Supt Scott agreed with Inspector Cox that the remoteness of the location of Mount Augustus presents some significant challenges when trying to get resources out there to try and undertake a search and rescue operation. There are also

52 T 24.

53 T 293.

54 T 292 – 294, 301.

55 T 300 - 302.

56 T 133 – 134.

57 T 134.

[2022] WACOR 29 challenges ensuring the safety of the responders, as the environment is harsh, so safety considerations need to be taken into account. A/Supt Scott also agreed with Inspector Cox that there were challenges using the aerial assets at Mount Augustus and communication challenges, due to the limited mobile phone coverage, which hampered the ability to establish a forward command and relay information back to the police command in Geraldton.58

47. All of these issues were considered at the inquest, and how they affected the search and recovery operations in relation to each of the deceased. Consideration was also given to whether improvements have been made, or if further improvements are needed.

EVIDENCE OF DR PAUL LUCKIN

48. Emergency Response personnel in Australia are very fortunate to have access to the expertise and guidance of Dr Paul Luckin when they are mounting search and rescue operations. Dr Luckin is a Specialist Anaesthetist, a Captain in the Royal Australian Navy and the Medical Advisor to the Australian Maritime Safety Authority and to the police and search and rescue teams across the entire nation, both Federal and State. Dr Luckin provides advice in relation to survivability, or time frames for survival, for land and marine searches. He is provided with as much detailed information as possible about the person who has gone missing and the circumstances in which they disappeared, and Dr Luckin will then construct the various scenarios in which survival may or may not be possible, and give an estimate as to how long he thinks the person or persons might survive in each of those scenarios.59

49. Dr Luckin has personally served in Bougainville, East Timor, Solomon Islands, Afghanistan and has attended disaster scenes such as after the Bali bombings and Banda Aceh following the tsunami.60 He has also walked the Kokoda trail and experienced dehydration and hyperthermia while doing so. Therefore, Dr Luckin’s evidence is based not only on his specialist training and experience assisting with search and rescues, but also from his own personal experience operating in extreme environments.61

50. Dr Luckin was consulted by WA Police to provide a timeframe for survival in the search for Mr Buske,62 and presumably for Mrs Ansell, but I understand not for Mrs Pollard and Mr and Mrs Green as their deaths were discovered fairly quickly.

However, Dr Luckin was asked by the Court to provide a report to assist in considering the deaths of all four deceased and to answer a number of questions about the adequacy of current warnings in relation to the risks at Mount Augustus, with a focus on future death prevention. Dr Luckin provided a comprehensive written report, and also gave evidence at the inquest to expand upon his report. In addition, Dr Luckin provided further material by letter after the inquest, to clarify some parts of his evidence at the inquest.

58 T 134 – 135.

59 T 108.

60 Exhibit 3, Tab 13.1, p. 23.

61 T 118, 128.

62 Exhibit 1, Tab 21.

[2022] WACOR 29

51. I am very grateful to Dr Luckin for the time and attention he committed to this matter. He gave his evidence thoughtfully and with compassion for the families of the deceased, many of whom were present either in person or by videolink for his evidence. He also went to the trouble afterwards of clarifying additional aspects that he felt were important. I have been greatly assisted by Dr Luckin’s opinion, both in understanding the risks that Mr Buske, Mrs Pollard and Mr and Mrs Green faced, as well as in considering what safety measures are appropriate for the future. I also understand the families who heard his evidence were very appreciative of the considerate manner in which he gave his evidence.

52. Having been provided with the particulars of all four deaths, Dr Luckin expressed the opinion that all of the deaths were consistent with dehydration and hyperthermia.63

53. At the outset of his report, Dr Luckin noted that “Mount Augustus will remain a dangerous place in high temperatures, which will be much of the year.”64 Dr Luckin also indicated that the question of preventing further deaths on Mount Augustus is complex, and “there are no popular or perfect solutions.”65 Dr Luckin observed that the “desire of tourism authorities and tourists to visit Mount Augustus will be diametrically opposed to the desire of police and other bodies to prevent deaths.”66 This still accurately reflects the position as I come to write this finding, after more than a year has passed since the last deaths and after hearing all of the evidence from the various people and organisations involved. Fortunately, no more deaths have occurred at Mount Augustus in the interim, but that is not to say the risks that Dr Luckin considered have resolved.

54. Dr Luckin has helpfully identified many of the risks and made some suggestions as to ways to manage those risks, without taking the option of closing the Summit Walk entirely.

Temperature

55. Dr Luckin observes that Mount Augustus stretches the boundaries of safety, especially in summer, and at times exceeds them. Dr Luckin made this comment with reference to charts that consider the relationship between air temperature, relative humidity (RH), sun exposure, work time (ie. hiking time in this case), water intake and risk. Dr Luckin explained that at 36°C, with a RH of 40%, a walker is already at the limit of the extreme caution zone shown in the Australian Army charts Dr Luckin used on deployment to Afghanistan; beyond this point, the risk increases very rapidly. From 37°C and above, a walker would fall into the extreme danger zone, where heat stroke or sunstroke is likely, and at 41°C and 40% RH, the risk of collapse and death from hyperthermia (increased body temperature) is very high. Dr Luckin stated that certainly, temperatures in the 40’s, and especially high 40’s, will result in some deaths.67 63 Exhibit 1, Tab 13.1, p. 14.

64 Exhibit 3, Tab 13.1, p. 2.

65 Exhibit 3, Tab 13.1, p.2.

66 Exhibit 3, Tab 13.1, p.2.

67 Exhibit 3, Tab 13.1, pp. 3, 8 - 9.

[2022] WACOR 29

56. Based on the Israeli chart example that Dr Luckin provided, which is used to guide hikers in the Israeli desert, at 36°C a hiker is in the extreme danger zone.68

57. It is important to note, that the abovementioned charts, do not include another factor that is present on Mount Augustus, namely, the additional factor of reflected heat from the rocks, which is a very significant factor in causing dehydration and hyperthermia, over and above that is caused by direct heat from the sun and the air temperature.69 Therefore, although Dr Luckin was estimating the RH on Mount Augustus, even at a lower RH, the high risk would remain.

58. Dr Luckin notes that the question of a maximum ‘safe’ temperature to attempt the walk is difficult, as it varies according to the individual’s risk factors and people’s confidence will often result in them overestimating their abilities. Dr Luckin also observed that any temperature limit applied would be difficult and contentious as Mount Augustus is a very popular attraction. Further, limiting access would be impracticable, given the terrain and its location.

59. Dr Luckin considers that further deaths in these circumstances “will be inevitable”70 and suggests that the only option is to make the risks very clear, and give explicit warnings, including that there is no possibility of assistance in an emergency.71 Dr Luckin recommends “major improvements in information across many sites, and in signage at the carpark.” Some people will still, of course, ignore this information and signage. But all of the evidence suggests that the people the subject of this inquest were sensible, law-abiding citizens who would have been likely to read, and heed, such warnings if they were prominently available.72 Mechanism of Death – Dehydration and Heat Stroke

60. In considering what warnings are required, it is important to understand how death occurs in these extreme temperatures, through dehydration and hyperthermia/heat stroke.

61. Dehydration is the condition in which the total amount of water in the body is lost.

Water is primarily lost through breathing, sweating and urination, but in a hot environment, most of the water is lost through sweating, as the body attempts to cool itself. Sweating is only possible if you are well hydrated. As you become dehydrated, the total volume of fluid in the body decreases and the ability to sweat decreases.

Fluid is then drawn from the bloodstream to try and give enough fluid to sweat, which means fluid is drawn from the tissues into the bloodstream to try and maintain circulatory volume. The inevitable result is that circulatory volume decreased, which means the blood pressure decreases and, hence, the flow of blood and therefore oxygen to all of the tissues in the body decreases. As the supply of oxygen decreases, the tissues become hotter and the metabolic system in the tissues is working faster 68 Exhibit 3, Tab 13,1, p. 9.

69 Exhibit 3, Tab 13.1, p. 9.

70 Exhibit 3, Tab 13.1, p. 8.

71 Exhibit 1, Tab 13.1, p. 8.

72 Exhibit 3, Tab 13.1, p. 3.

[2022] WACOR 29 and consuming more oxygen, which produces acid. This increases the rate at which the body heats up, at the same time that the body is losing the ability to cool itself.73

62. Dehydration also severely affects decision making skills. The sensation of thirst is lost early as dehydration and hyperthermia progress, which accelerates both dehydration and loss of mental capability. The person becomes confused, which progresses to irritability and decreased level of consciousness. Interestingly, Dr Luckin explained at the inquest that this can lead to the irrational result that a person who is severely dehydrated, may not think to drink water, even when it is available.

It is not uncommon for people to collapse and die from dehydration and hyperthermia while still carrying water, or to walk past water without thinking to drink it. They will even refuse water if it is offered. This seems to have occurred in Mr Buske’s case, as he was found with a half-full bottle of water next to his body. Dr Luckin explained it is because of this phenomenon that people are encouraged to drink continuously, rather than waiting to be prompted by thirst.74

63. The physiology behind this is decreasing blood flow and oxygen supply to the brain, which leads to swelling increasing pressure in the brain, and hence altered level of consciousness. There is a breakdown of cell membranes throughout the body, with the release of cellular enzymes into surrounding tissues. These enzymes break down the tissues, releasing more heat and accelerating the increase in body temperature.

Within the brain, this causes collapse, possibly convulsions, and death. The breakdown of tissues shows the characteristics of decomposition at post mortem examination. Blood-stained fluid collects in the air sacs in the lungs due to the breakdown of pulmonary alveoli and there is damage to the heart muscle, seen at post mortem as similar damage to a recent heart attack.75

64. Dr Luckin set out in detail the three stages of dehydration and hyperthermia:76

• Initial stage - Heat cramps: painful muscle cramps, especially in calf and legs, because these muscles are working hardest and generating heat;

• Second stage - Heat exhaustion: dehydration + headaches, nausea, vomiting, loss of thirst, loss of appetite, irritability;

• Third stage - Heat stroke increasing irritability, confusion, disordered thinking progressing to irrational behaviour, sudden collapse, loss of consciousness, convulsions, death.

65. Dr Luckin explained that the transition from irritability, confusion and disordered thinking to collapse, convulsions and death is sudden and rapid, often occurring within seconds.77 By the time the person has reached that third stage, survival is virtually impossible, even with treatment.78

73 T 111, 115.

74 T 117; Exhibit 3, Tab 13.1, pp. 7 - 8.

75 Exhibit 3, Tab 13.1, pp. 4, 14.

76 Exhibit 3, Tab 13,1, p. 6.

77 Exhibit 3, Tab 13.1, p. 6.

78 T 116.

[2022] WACOR 29

66. The evidence in these cases indicated that all of the deceased had lain down prior to death, rather than having fallen from standing height. This was explained by the fact that in the setting of heat stroke, the heart is unable to pump blood so the person becomes lightheaded and needs to lie down in order to maintain circulation. Dr Luckin indicated a severely hyperthermic, tired and dehydrated person will feel exhausted and will typically sit or lie down, which is followed shortly after by sudden collapse and rapid death. This means the body is often found in a lying position, on the back or side, with clothes and equipment in place, as the lying down is a deliberate move, but probably one of the last reflexes before the person dies.

That is exactly what appears to have occurred in the four cases the subject of this inquest.79 Inadequacy of Current Warnings

67. Dr Luckin expressed the opinion that the current warnings do not adequately inform hikers of how dangerous the walk is, at any time of year, but especially in the hotter summer months.80 He suggested some modifications, indicating that unfortunately, in his experience, the “warnings have to be very blunt, otherwise people think they know better, and ignore the warnings.”81 An example given is the continued deaths of rock fishermen at Salmon Holes in Albany, despite the many warnings in place.

68. I have addressed Dr Luckin’s suggestions in the proposed recommendations section below. In summary, Dr Luckin suggests warning people that the walk is long and strenuous and not suitable for people with limited or no experience in harsh conditions, or who are not acclimatised to the weather, or have heart or lung conditions. Some of the reasons for that are explained next.82

69. Dr Luckin also considers the warnings do not adequately advise of what equipment needs to be taken, if attempting the walk. For example, Dr Luckin believes the current recommendation to carry 3 to 4 litres of water per person is not adequate; a minimum of 6 litres per person should be standard.83 That is so that the person can consume one litre per hour. If people walk more slowly, or lose more fluid by sweating, then they would need to carry more than 6 litres. Dr Luckin explained that the one litre per hour rule applies to any intended walk, and if not followed, the person may complete the walk but will be dehydrated and will suffer some damaged health afterwards. As noted above, dehydration causes a progressive deterioration in survival ability.

70. However, it is important to note that sufficient water will also not, on its own, guarantee survival. Dr Luckin emphasised that it needs to be a combination of the appropriate preparation (clothing, the right time of year, proper hydration, the timing of the walk during the day) for the appropriate people (without significant medical conditions).84 79 T 73, 116; Exhibit 3, Tab 13.1, p. 7.

80 Exhibit 3, Tab 13.1, p. 3.

81 Exhibit 3, Tab 13.1, p. 6.

82 Exhibit 3, Tab 13,1, p. 6.

83 Exhibit 3, Tab 13.1, p. 3.

84 T 121.

[2022] WACOR 29

71. In terms of the time of day, Dr Luckin reviewed the sunrise and sunset times for the different times of the year at Mount Augustus and in the hotter months, sunrise is at about 5.30 am. At those times, Dr Luckin suggests a person should preferably start the walk at sunrise and should not start the walk after 6.00 am, half an hour after sunrise. Having said that, like Mr Snowball, Dr Luckin indicated he would not personally do the walk in the summer months.85

72. Dr Luckin recommended that people also carry food and they should eat small amounts frequently. He suggests high energy foods, such as nuts and fruit, are best, and people should avoid very sweet foods, such as muesli bars.86

73. In terms of clothing, Dr Luckin noted that clothing is a very important part of protecting people from hyperthermia. Dr Luckin explained that a broad-brimmed hat is very important to protect the head from heat from the sun, and because of the reflected radiant heat from the rock, it is also very important that the arms and legs are fully covered. The usual ‘shorts and t-shirt’ attire worn by the average Australian with the idea that you will feel cooler and more comfortable, is simply insufficient to protect a person in this environment. Dr Luckin pointed to the long loose clothing worn by the Arabs in the desert as a good example of how to dress to stop radiant heat while still allowing air flow underneath.87 Specific Risk Factors

74. There are greater risks for the elderly (using the arbitrary age of 65 years and above) attempting the Summit Walk, as they are at greater risk of dehydration, both because they are generally less well hydrated to start with and because they are less likely to drink plenty of fluid even when dehydrated. They are also likely to take longer to complete the walk, therefore spending longer exposed to hot conditions. Therefore, there is a much greater risk of death for people in this age category attempting the long hike.88

75. The Forensic Pathologist, Dr Vagaja, agreed in her evidence at the inquest that, putting to one side any particular health issues of the people the subject of this inquest, there was a risk factor or potential bad outcome on Mount Augustus for at least Mr Buske and Mr and Mrs Green, simply given their ages of 69, 70 and 66 respectively. That was the case, even if they had been in pristine health, with no preexisting disease.89

76. It was not relevant to this case, but it was raised in evidence that similar risks apply to children under 4 years of age, as they have not yet developed temperature control mechanisms. Dr Lucking indicated children under 4 years should not be taken or carried on Mount Augustus for that reason.90

85 T 122.

86 T 115; Exhibit 3, Tab 13,1, p. 13.

87 T 110, 129.

88 Exhibit 3, Tab 13.1, p. 3.

89 T 83.

90 Exhibit 3, Tab 13.1, p. 13.

[2022] WACOR 29

77. There are also medical conditions, that can affect people of any age but are often more common in the elderly, that can increase the risks of the hike, both because of dehydration and by reducing the body’s ability to regulate its temperature.91 All of the people who died had some of these pre-existing health issues, as did Mr Pollard, who was very lucky to have survived. Dr Luckin expressed the view that people should not attempt the Summit Walk if they have:92

• Heart problems or high blood pressure;

• Reduced kidney function, as they are at extreme risk if there is decreased perfusion to the kidneys due to dehydration;

• Hip, knee or back problems, as it will be harder and take them longer to do the walk, and increase the risk they may not be able to complete it and get stranded in the heat with nowhere to shelter; or

• Lung problems (asthma, chronic obstructive airways disease, bronchitis or a recent chest infection), and more recently anyone recovering from COVID would also fall into this category.

78. Dr Luckin also noted that people with diabetes, even if it is fairly well-controlled, will often have damage to the kidneys and reduced renal function, so diabetes is also a very high risk factor for that reason. If people with diabetes and/or reduced kidney function do wish to attempt the walk, they will need to ensure that they are extremely well-hydrated, as any level of dehydration can put extra strain on the kidneys.93

79. Some medications also decrease the ability to stay hydrated and to respond appropriately to heat, including medication for:94

• High blood pressure and heart problems (beta blockers, diuretics), which reduce the person’s ability to increase their heart rate in response to exercise and affect peripheral circulation and the ability to respond to changes in the environment;

• To reduce allergy symptoms (antihistamines); and

• Anxiety (tranquilizers) or mental health symptoms (antipsychotics), which can cause sedation.

80. Illicit drugs such as cocaine and amphetamines are also a risk factor, as they increase the heart rate and body core temperature and promote overheating. Further, more than ‘moderate’ alcohol consumption can increase the risk to a person, both through any residual effects of excess alcohol affecting good judgment, as well as diminishing the quality of restful sleep the night before. Noting that everybody interprets “modest” or “reasonable” differently, just like what the view of what constitutes “fit” differs, Dr Luckin suggests that the best advice would be to avoid any alcohol the night before the walk, and it certainly should not be taken on the walk.95 91 T 111; Exhibit 3, Tab 13.1, p. 3.

92 T 111 - 113; Exhibit 3, Tab 13,1, p. 3.

93 T 112.

94 T 111, 113.

95 T 113 - 114; Exhibit 3, Tab 13.1, pp. 5, 13.

[2022] WACOR 29

81. Where the person has come from, and what opportunity they have had to acclimatise to the weather conditions in Mount Augustus is also a risk factor. Acclimatisation is the physiological process by which the body learns to increase the rate at which it sweats in a hot environment in order to cool down more. People coming from cool climates, such as Western Europe, or even cooler Australian states such as Victoria and Tasmania, have a very limited ability to cool by sweating. In order to acclimatise to a hotter climate, such as at Mount Augustus, and increase their ability to sweat and regulate their body temperature, Dr Luckin indicated a person would need to spend a minimum of 14 days in the new environment, with graded exercise and exposure. In that time, they can increase their rate of sweating from 500 mls/day to as much as 1 litre/hour, so it is a significant change. The body also adjusts the concentration of salt in the sweat, lowering it so less salts are lost as the body sweats more. People coming from a place with a warmer climate, such as Perth, would be in a far better position to cope with the hotter weather at Mount Augustus, although depending on what time of year they come, there may still need to be a small period of acclimatisation. Dr Luckin emphasised in his evidence that visitors who are not acclimatised are at a major disadvantage as their body does not have the ability to get rid of heat by sweating. As a result, they are at high risk of hyperthermia, collapse and death.96

82. Excess weight can also reduce the body’s ability to cool, as fat is a very good insulator and decreases the ability to lose heat through sweating, which increases the risk of overheating and death. People with a BMI over 30 (which is classified as obese) are, therefore, at greater risk of hyperthermia.97

83. Experience in undertaking such an arduous walk is also important, and being appropriately dressed for the event. Visitors who are not familiar with the harshness of the conditions may underestimate their level of experience and what equipment they require. Dr Luckin noted specifically that inexperienced hikers are more at risk as they are more likely to:98

• Underestimate the difficulty of the walk;

• Ignore safety advisory warnings;

• Carry insufficient water;

• Fail to recognise the signs of dehydration and push on when already dehydrated, overheated and tired;

• Fail to understand that reaching the summit is the easier part of the walk – the return is just as long, but they will already be tired and hot, the weather will be hotter and the rocks can be slippery and harder to walk down than up;

• Venture off-track; and they are less likely to:

• Have appropriate clothing (lightweight, preferably cotton, light in colour to reflect heat, loose fitting and long to cover arms and legs from the sun);

• Wear a broad-brimmed hat, which is essential, or even carrying an umbrella;

• Wear appropriate footwear;

• Ask others for help when required; and

• Have informed someone of where they are and when they will return.

96 T 108, 121; Exhibit 3, Tab 13.1, p. 12.

97 T 114; Exhibit 3, Tab 13.1, p. 13.

98 Exhibit 3, Tab 13.1, pp. 12 – 13.

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84. As I indicated above, I will address later in the findings the particular warnings Dr Luckin suggests should be given to tourists in order to highlight some of these risk factors, and help them to make a proper risk assessment, but it is sufficient at this stage to note that Dr Luckin gave evidence that it is absolutely essential that they should know that they need to acclimatise and if they are not acclimatised, “then walking in that hot environment is extraordinarily dangerous.”99 That risk is compounded if they are elderly. Dr Luckin suggested that a thorough health check for elderly people considering attempting the walk would be beneficial, but acknowledged that it would be a difficult thing to convince people to do.100

MR AND MRS BUSKE

85. Mr Buske was born in Berlin, Germany in 1950. He was 69 years of age when he flew with his wife from Berlin to Western Australia. His wife was 57 years of age.

Mr Buske was a retired freelance writer and kept active and healthy in retirement playing golf and tennis most days. His wife believed he had undergone brain surgery in about the year 2000, but since they had been together from 2004, he had not experienced any significant health issues. Mr Buske and his wife enjoyed travelling together and each year they went on one big overseas trip. They had travelled to New Zealand and Australia before, and in 2019 they planned a three week trip to Western Australia.101

86. Mr and Mrs Buske flew to Perth from Berlin, via Qatar, on 3 November 2019. They had a number of things to do on their ‘wish list’ but no concrete plans. They had agreed that, if time permitted, they would travel to Mount Augustus, Coral Bay, Shark Bay and the Pinnacles. When they landed in Perth they rented a car, a Mitsubishi Pajero, at the airport and then stayed in Perth for a couple of days, before driving north to Carnarvon on Thursday, 7 November 2019. They travelled direct to Carnarvon from Perth and stayed the night at a motel in Carnarvon.102

87. At around 11.00 am on Friday, 8 November 2019, the couple left Carnarvon to travel to Mount Augustus. Before leaving, they had purchased some groceries at the local supermarket to take on their trip. On the journey, they stopped at Gascoyne Junction to refuel. While there, they spoke a lady at the roadhouse who advised them it would take another four hours to reach the Mount Augustus Tourist Park. They continued driving and eventually arrived at the Tourist Park at approximately 5.00 pm. They booked a room at the Tourist Park for two nights. After checking into their room, the couple had dinner, watched some television and went to bed.

88. Mr and Mrs Buske planned to walk to the summit of Mount Augustus the next day.

Mrs Buske later told police that she believed she had done the necessary research and they knew what to expect.103 They had seen the weather forecast the night before, indicating the temperature could reach 42°Celsius that day, so they were aware that it was going to be hot. Mrs Buske told police that she and her husband had also done

99 T 109.

100 T 112.

101 Exhibit 1, Tab 1 and Tab 5.

102 Exhibit 1, Tab 1 and Tab 5.

103103 Exhibit 1, Tab 1, p. 21.

[2022] WACOR 29 some research on the internet about Mount Augustus, which had also made it clear that it was going to be hot out in the area and recommended they take three litres of water per person for the Summit Walk, which they understood would take between six to eight hours in total from the carpark to the summit and back again. Mrs Buske indicated the only thing they had not appreciated at that stage was the nuisance factor of the ever present flies, which they found challenging to deal with and led them to wear fly nets to keep the flies off their faces. Otherwise, at the early stages, Mr and Mrs Buske believed they were fit enough and well informed enough to embark on the walk.104

89. Mr and Mrs Buske woke up at about 5.00 am on Saturday, 9 November 2019, ready for the walk that day. They had breakfast then drove out of the Tourist Park to the Flintstone Rock - Beedoboondu carpark, which is the base of the Mount Augustus summit trail. They arrived at about 7.20 am and parked their car near the walking track. There were no other cars in the carpark and no one else around at that time. Mr and Mrs Buske noticed the weather was a lot warmer by that time, but they were not worried as they had expected it would be hot, so they were not deterred from commencing the walk.105

90. As they set off on the journey towards the summit, Mrs Buske recalled their intention was to reach the summit, but “it wasn’t a must to get there”106 and they were aware they could turn back at any time if they didn’t feel well. Their plan was to go slowly and take their time and not rush.107

91. Both Mr and Mrs Buske were wearing shorts, t-shirts, hats and fly nets and they were both carrying small backpacks. They each carried three one and a half litre bottles of water in their back packs, along with some food, and also each carried a small 600 mm bottle of water in their hands that they used to drink from while they were walking.108

92. Mrs Buske recalled she found the first part of the track to be easy to navigate due to little blue trail markers along the path, and she felt the walk was easy up to the 110 metre mark. It took them between 30 and 40 minutes of walking to reach this point.

They stopped here and had a short 10 to 15 minute break, which included having a drink. Mr and Mrs Buske spoke to each other at this time and everything appeared fine. After the break, they continued walking up towards the summit.109

93. Mrs Buske remembered the next stage of the trail was steeper and rockier and a lot harder to navigate. They were both walking slowly and taking a lot of rests, but Mrs Buske still found that she was often ahead of her husband and would have to stop and wait for him. When he caught up, they would talk for a little bit then continue on again. Once they reached the 450 metre mark, they both stopped and had a good rest.

Mrs Buske was not sure exactly how long it took them to travel from the 110 metre mark to the 450 metre mark, but believed they stopped there at about 10.30 am. They found some shade under a bush and had a drink and a snack of some nuts. Both Mr 104 Exhibit 1, Tab 1 and Tab 5.

105 Exhibit 1, Tab 5.

106 Exhibit 1, Tab 5 [49].

107 Exhibit 1, Tab 5.

108 Exhibit 1, Tab 5.

109 Exhibit 1, Tab 5.

[2022] WACOR 29 and Mrs Buske were hot and sweating by this time, and they knew they had to drink plenty of water to replenish. Mrs Buske recalled that the trail was a lot harder than they had though it would be and she felt her energy had gone down a bit by this stage. Mr Buske also mentioned to her that he was tired and had lost energy, which was unusual for him. Despite both feeling tired, they both felt ready to continue their journey, so after their break they kept walking towards the summit.110

94. Mrs Buske noticed the ground was now flatter and easier to walk. They missed a couple of the trail markers, so they were not sure what distance they had travelled, but they were confident they were still on the trail. After walking for about thirty minutes more, Mr and Mrs Buske stopped again and decided that they “had had enough.”111 They were both in agreement that they wanted to turn back without reaching the summit. They rested for about 20 minutes then started to head back down at midday. Mrs Buske recalled that it was still hot, but did not feel hotter than when they had started the walk and there was a fresh wind blowing. Neither of them was particularly thirsty, but they continued to drink water as they knew they had to keep hydrated.112

95. Mrs Buske recalled they walked slowly from the 450 metre mark to the 110 metre mark and had a lot of little short breaks on the way. They were walking a couple of metres apart as they walked. Mrs Buske remembered Mr Buske remarking at one stage that he would be happy when he was back at the car. When they reached the 110 metre marker they stopped again and found some shade close by to the bench where they sat to have a rest. They rested for about 20 minutes and had a drink. They were both finding the journey a bit harder by this stage, but it seems Mrs Buske was managing a little better than her husband.113

96. When they left the 110 metre marker point, Mrs Buske took Mr Buske’s backpack from him and carried it for him as he was struggling. She filled up his 600 mm bottle before they left the marker and noticed that two of his one and a half litre water bottles were empty and the third bottle was half full, whereas she had only drunk one of her three bottles. Mr Buske was carrying the small 600 mm bottle as they began walking again. Mr Buske was walking ahead of his wife at this time, and was eventually about 30 to 40 metres in front of her as she was walking more slowly than him. She recalled seeing him sit down at one stage before he walked off again. They then walked into an area where the trees were taller and she lost sight of him.114

97. Mrs Buske continued walking slowly, assuming Mr Buske was walking on ahead of her. She arrived back at their car in the carpark at 3.35 pm. Mr Buske was not at the car when she arrived, which surprised her. She called out for him and walked around a bit, calling out his name, but did not hear anything in response. She was exhausted and did not have enough energy left to go back up the track to look for him. Instead, she rested at the shaded area at the start of the trail for 10 to 15 minutes, hoping he would arrive there, but he did not return. Mrs Buske eventually walked back a little bit up the summit trail, estimating she walked 200 to 300 metres, calling out his 110 Exhibit 1, Tab 5.

111 Exhibit 1, Tab 5 [83].

112 Exhibit 1, Tab 5.

113 Exhibit 1, Tab 5.

114 Exhibit 1, Tab 5.

[2022] WACOR 29 name, but she did not hear or see him. She looked for him until about 4.00 pm without success and then she started to become very worried.115

98. Mr Buske had the car keys with him so she was unable to get into the car at this time.

She tried to pry open the window and then tried to smash a back window with a rock, but the glass would not shatter. She realised she would have to leave and go and get help as she had no mobile phone reception and there was no one else around. Mrs Buske was aware that the nearest populated area was the Tourist Park and homestead, which was about 10 km away, so despite her exhaustion she started to walk back toward the Tourist Park on the Loop Road, which circles Mount Augustus and connects all of the visitor carparks. Mrs Buske had walked approximately 1.5 kilometres and nearly reached the Pound carpark when she saw a car approaching and waved it down. The car stopped and Mrs Buske spoke to the occupants, Patrick O’Leary and Kellie Nelson, explained the situation and asked for their help.116

99. Ms Nelson was working as a governess at a station a few hours away and she had driven with her friend Mr O’Leary, who was visiting her, to Mount Augustus to sightsee. They were aware that the forecast was for hot weather at Mount Augustus that weekend but had gone anyway as Mr O’Leary had to leave soon so they couldn’t wait for cooler weather. They were driving along Loop Road to find a spot to watch the sunset when they came across Mrs Buske walking on the side of the road at about 5.00 pm. Although Mrs Buske is German, she can also speak English, and she explained that her husband was lost and she needed help. It was 5.10 pm when they headed back to the Flintstone carpark with Mrs Buske to try to find her husband.

When they arrived at the carpark only Mr and Mrs Buske’s hire car was there and Ms Nelson recalls the weather conditions were “stifling.”117 Ms Nelson confirmed the hire car was locked and she and Mr O’Leary had a quick search around and called out Mr Buske’s name without any response. It was getting late so they quickly decided that they needed to go back to the Tourist Park to raise the alarm.118

100. Mrs Buske wrote a note to Mr Buske in German explaining that she was going to get help, tucked it under the wiper blade on the back window of her car and left a bottle of water next to car, before driving away with Mr O’Leary and Ms Nelson to the Tourist Park. When they arrived at the Mount Augustus Tourist Park, Mrs Buske went into the office and spoke to a staff member at the Tourist Park, who immediately called the police to report Mr Buske missing. Mrs Buske rang her sons in Germany to tell them what had happened and then waited at the Tourist Park office for the police to arrive.

101. After leaving Mrs Buske at the office, Ms Nelson and Mr O’Leary drove back to the Flintstone carpark to search again for Mr Buske. When they arrived at the carpark the hire car was still there and still locked and nothing had changed from when they had left. They had brought torches with them and Mr O’Leary used a witch’s hat from the Tourist Park to use as a loudspeaker in the hope that might help Mr Buske hear them. They walked along the trail while calling out Mr Buske’s name but got no response. Ms Nelson, who was a relatively young woman in her mid-thirties, 115 Exhibit 1, Tab 5.

116 Exhibit 1, Tab 1, p. 5 and Tab 5.

117 Exhibit 1, Tab 6 [24].

118 Exhibit 1, Tab 6.

[2022] WACOR 29 remembered it was very warm and tiring walking up to the 110 metre mark, which took them about an hour. When they returned to the carpark it was dark. Mr Hammarquist from the Tourist Park met them in the carpark and he told them he had been able to hear them calling out very clearly from where he was standing. After a brief discussion, all three of them returned to the Tourist Park.119

102. In the meantime, Brevet Senior Sergeant Sheryl Jackamarra, who was the Officer in Charge of the Burringurrah Multi-Function Police Facility, which is the nearest police facility to Mount Augustus, had received a call from Geraldton Police Station advising that there was a missing person on Mount Augustus. BSS Jackamarra was on a rostered day off but she immediately did some background work to find out more information, then travelled to the Tourist Park to speak to Mrs Buske and the Tourist Park management. BSS Jackamarra spoke to Mrs Buske and obtained her account of what had happened that day. She then drove to the Flintstone carpark, arriving at about 10.30 pm. BSS Jackamarra could see Mr and Mrs Buske’s hire car in the carpark but no person or other vehicle. She turned on the lights and siren of her police car and sat for a moment before turning them off again and listening to hear if there was any response. She heard nothing and could see nothing with her torch or vehicle headlights BSS Jackamarra took some photographs of the notes Mrs Buske had left then eventually left the carpark and headed back to Burringurrah MFPF, where she updated the police recording systems, knowing that a full search for Mr Buske would be commenced.120

THE SEARCH FOR MR BUSKE

103. Acting Inspector Brendon Barwick was stationed at the Geraldton Police Complex at that time as part of the Mid-West Gascoyne Police. At about 5.00 pm on Saturday, 9 November 2019, he received a mobile call informing him that there was a missing male hiker at Mount Augustus. A/Insp Barwick is a qualified Land Search Controller. He immediately went to the Geraldton Police Station and commenced planning for a land search to locate the missing person, Mr Buske. Throughout the evening A/Insp Barwick coordinated the initial response to providing logistics to run a search in that remote location.121

104. Approval was given for a night search to be conducted using an aircraft with infrared equipment. The air search was scheduled for around midnight to allow the ground to cool off sufficiently to show the temperature variants in the search area.

Unfortunately, the air search was unsuccessful as the ground temperatures remained too high.122

105. A/Insp Barwick also rang the nurse at Burringurrah Community Medical Centre to ask if the nurse could attend Mount Augustus in case the missing hiker was found and required medical assistance. The request was declined as the nurse advised he was not authorised to leave the community due to contractual arrangements. He suggested that the RFDS should be contacted. RFDS were then contacted and Jake Polkinghorne at the RFDS Control Centre advised RFDS could only assist once the 119 Exhibit 1, Tab 6.

120 Exhibit 1, Tab 9.

121 Exhibit 1, Tab 10.

122 Exhibit 1, Tab 10.

[2022] WACOR 29 person was found. In addition, if the person was found at night, the plan would need to land at Burringurrah Airstrip, some 40 km away, due to runway lighting requirements. If the person was found in daylight hours, the RFDS plane would be able to land at the Mt August Airstrip, which is situated closer to the area than Burringurrah Community, but on the opposite side of Mount Augustus to the search location. The RFDS had aircraft available at Meekatharra that could assist.123

106. A/Insp Barwick ceased duty at midnight and left another officer to monitor the situation so he could go home and get some sleep, before recommending duty at 6.00 am on Sunday, 10 November 2020, taking on the role as the Police Search Commander within the Incident Management Team.124

107. Ms Nelson and Mr O’Leary got up at 4.00 am on Sunday, 10 November 2019, and met up with another three people in the Tourist Park who had offered to search for Mr Buske, including Jennifer and Stephen O’Neil who were there on holiday from Queensland. The five of them drove to the Flintstone carpark, where they found the Buske’s hire car still there and still locked. They checked the toilet, which was close by, but found no sign of Mr Buske. The five of them then walked back up the trail to the 110 metre mark, starting the walk at about 5.00 am. It was already warm by this stage and hard going. At that point, Mr and Mrs O’Neil decided to continue on up to the summit and the other three returned to the carpark. On their way back down they panned out from the trail looking for Mr Buske but found no sign of him. When they reached the carpark Mr Don and Mr David Hammarquist were there and they told them what they had done to look for Mr Buske. It was about 7.30 am by this time.

Ms Nelson and Mr O’Leary felt there was little more they could do to help at that stage, so they left to go to another area of the park, before returning later that morning to speak to the police who were conducting the official search for Mr Buske. They were asked to join the formal search, which they did, but they never found any sign of Mr Buske.125

108. Mr and Mrs O’Neil had continued up the trail and arrived at the summit at 7.40 am.

It was warm at the top of the mountain and they stayed there for about 10 to 15 minutes before making their way back down. As they were heading down from the summit, Mrs O’Neil noticed that side of the mountain was now in the sun. It was very hot and the conditions of the trail they took felt harder. When they reached the 110 metre mark again they met police officers and some volunteers and told them they had been to the summit and seen no sign of Mr Buske. They offered to help with the search but were told SES volunteers were on their way to help and they weren’t required so they returned to their car. Mrs O’Neil noted they had taken 8 litres of water with them for the walk to the summit and they had about half a litre left on their return. Mr and Mrs O’Neil have completed similar walks to this one before and she described the Summit Walk as moderately difficult, but the temperature and distance made it different to most. She considered the trail was fairly well marked.126

109. BSS Jackamarra left Burringurrah Community very early and drove straight to the Flintstone carpark, arriving at about 6.00 am. Her colleague was on leave at the time, 123 Exhibit 1, Tab 10.

124 Exhibit 1, Tab 10.

125 Exhibit 1, Tab 6 to Tab 8.

126 T 192 – 193; Exhibit 1, Tab 7.

[2022] WACOR 29 so she was on her own. On arrival she was met by Don and David Hammarquist. She spoke to them and confirmed that there was no new information since her previous attendance and Mr Buske had still not been found. BSS Jackamarra did a short search herself then drove to the Tourist Park where a Forward Command Post was being set up with Sergeant Peter Gerada to command the incident from the ground, liaising with A/Insp Barwick back in Geraldton.127

110. Sgt Gerada had left Carnarvon at 2.00 am in order to arrive at the Mount Augustus Tourist Park at 8.00 am on the Sunday morning. As well as Sgt Gerada, other police officers were present and SES volunteers were also arriving from Perth via Police Airwing. BSS Jackamarra ensured that local resources were available for the search team, and took on a family liaison role, providing support and information to Mrs Buske, who was still hopeful that her husband might be found alive and well. BSS Jackamarra also advised that she had a personal Optus phone, which gave her communications within a 2 km of the newly installed Optus tower, so she assisted the other Forward Command Team members by letting them use her phone as their Telstra phones were not operational.128

111. Sgt Gerada went to the Flintstone carpark and noted the hire car was still there. He also noticed that there was quite dense bushland around the base of Mount Augustus.

He reported back his conclusions about the terrain to the Geraldton Incident Control Centre and then took a small search team along the summit trail. Once they reached the 110 metre mark, which Sgt Gerada understood was the last place Mr and Mrs Buske had rested together before the descent, they then commenced a search all the way down to the base of the mountain, a distance of approximately 1.5 kilometres.

They finished the initial search of the summit trail at 1.00 pm without any sign of Mr Buske. Sgt Gerada then organised for a local helicopter to conduct searches of the vicinity with a volunteer SES observer while he returned to the Tourist Park and briefed SES search teams.129

112. A/Insp Barwick recalled that defining probable search areas was heavily reliant on information provided by Forward Police Commander Sgt Gerada, but this was made even more difficult by the fact that communication was almost non-existent at the search scene. This required the Police Forward Control to leave the area to obtain Optus mobile phone coverage. Satellite phone communication was also sporadic at best. Arrangements were made to deploy Police Radio Support Unit to the location to erect communication towers to try to resolve the issue, and a drone operator was also sent there to assist with the search.130

113. Sgt Gerada returned to the Flintstone carpark with the SES personnel. The team of searches conducted a search of various walking trails and outward from the carpark, including with the assistance of a search dog, ending at 8.00 pm when the conditions became too dangerous to continue searching. No sign of Mr Buske was found that day.

127 T 193; Exhibit 1, Tab 9 to Tab 11.

128 T 194; Exhibit 1, Tab 9 to Tab 11.

129 Exhibit 1, Tab 11 and Tab 12.

130 Exhibit 1, Tab 10.

[2022] WACOR 29

114. The police had liaised with Dr Luckin. Based upon what was known at the time, Dr Luckin had advised that Mr Buske had most likely become hyperthermic early in the walk, which posed an immediate threat to his life. Dr Luckin did not think it was likely Mr Buske would have walked far and it was very possible he was already deceased. If still alive, he would likely be immobile and non-responsive to efforts of searchers to communicate with him by that stage. It was thought Mr Buske would probably be sheltered under trees or rocks within a short distance off the main walk track. Noting what he was wearing, Dr Luckin noted Mr Buske would be extremely difficult to see, even from ground level. Mr Buske’s chances for survival that night were estimated, at 25% at most. Dr Luckin initially considered it was not possible he would survive past midday on Monday, 11 November 2020, although this was later extended slightly when more information came in about the amount of water he had consumed on the walk. Nevertheless, time was of the essence and all efforts were made to try to locate Mr Buske as quickly as possible.131

115. During the afternoon of Sunday, 10 November 2020, A/Insp Barwick was relieved as Police Search Commander by Inspector Darryl Cox. A briefing was held that evening and strategies and plans were devised for the next day’s search.132

116. The search recommenced at 4.30 am on Monday, 11 November 2019 with the canine search team, who were joined by SES search teams at 6.00 am. Detective Sergeant Bruce McDonald from Geraldton Detectives had been recalled to duty and tasked to attend the scene on the Sunday. He went to Carnarvon for a briefing then recalled another police officer to duty, Constable Paul Havenstein, who was on a week’s leave, and they travelled together to Mount Augustus, arriving at about 10.00 pm.

They commenced duty at 5.30 am on the Sunday morning and met at the Command Post at the Tourist Park. Det Sgt McDonald was introduced to Mrs Buske at 6.00 am and he obtained a statement and information from her to help try and find her husband.133

117. After some discussion about what she remembered, at Det Sgt McDonald’s request Mrs Buske returned with him to Mount Augustus and tried to retrace her steps and show the police where she had last seen her husband. They parked in the carpark at about 10.00 am and then walked back up the trail to the 110 metre mark. Mrs Buske found it difficult to identify the spot on the track where she had lost sight of him. It was extremely hot and humid and Mrs Buske would no doubt have been very tired and distressed, although Det Sgt McDonald made sure to check that she was feeling okay and comfortable. When they returned to the carpark, Mrs Buske rested in the shade area in the company of Det Sgt McDonald while other police officers continued to search the area.134

118. Constable Havenstein had headed off the main track on the descent and tried to follow the path of least resistance, keeping in mind that Mr Buske could have been suffering from heat exposure and possibly delirium, and may have been naturally following the simplest path down. About 100 metres prior to the carpark, Constable Havenstein followed a slight creek bed, rather than the main track, noting in parts it 131 Exhibit 1, Tab 19, p.10, 18 and Tab 21.

132 Exhibit 1, Tab 10.

133 Exhibit 1, Tab 13.1 and Tab 19.

134 Exhibit 1, Tab 13.1.

[2022] WACOR 29 was reasonably flat. At about 11.30 am, Constable Havenstein was on the southern side of the creek bed when he turned back towards the carpark, walked through a wall of shrubbery and over a slight ridge and came across Mr Buske. Mr Buske was lying face down in the sand, slightly on his side. Constable Havenstein called out to Mr Buske and ran to him, but quickly realised Mr Buske was deceased and appeared to have been for some time. Mr Buske was still fully clothed and wearing his flynet.

He had a partially filled water bottle lying beside him.135

119. Constable Havenstein marked the spot so that he could easily find it again, then walked the short distance to the carpark. He advised Det Sgt McDonald he had found Mr Buske’s body approximately 200 to 300 metres away, but well off the walking trail. They left Mrs Buske in the shaded area and returned together to Mr Buske’s location. There were no signs of a disturbance around Mr Buske’s body and he had no obvious signs of injury, other than minor scratch marks on his legs consistent with having walked through the scrub/bush area off the main track. Det Sgt McDonald went back and told Mrs Buske they believed they had found Mr Buske’s body not far away. He then arranged for Mrs Buske to be taken back to the Tourist Park and then flown to Perth to be assisted by the German Consulate.136

120. The police later found the keys to the hire car still in Mr Buske’s shorts pocket. A later check of the car found it still locked and the note written by Mrs Buske still on the back window, suggesting he never made it back to the car.137

121. Based upon what she has been told about where her husband was found, Mrs Buske believes he must have walked off the track and become lost on the way back to the car. Although they had stopped and recuperated, she recalls they were both still exhausted and this may have affected has ability to find his way safely to the carpark as she believed the trail at the point was well marked and relatively easy to follow.138

122. Det Sgt McDonald used a satellite phone to advise Inspector Cox at about midday that Mr Buske’s body had been found. Det Sgt McDonald and Constable Havenstein photographed and recorded the scene. Constable Havenstein confirmed Mr Buske’s death at the scene before he was transported to the Burringurrah Community Nursing Post. His identity was later confirmed by a forensic odontologist from his dental records.139 140

123. The Incident Management Team was disbanded after the extraction plan was executed to return all staff home. Just to give some indication into the scope of that, I have inserted the extraction plan below.

135 Exhibit 1, Tab 14.

136 T 19; Exhibit 1, Tab 13.1 and Tab 14.

137 Exhibit 1, Tab 14.

138 Exhibit 1, Tab 5.

139 Exhibit 1, Tab 3 to 4 ant Tab 12 to 14.

140 Exhibit 1, Tab 1, p. 5.

[2022] WACOR 29 Exhibit 1, Tab 19 – Extraction Plan

124. In terms of the support provided by locals on the ground, Mr Hammarquist indicated that after staff initially became involved in notifying police that Mr Buske was missing, and assisting police with local knowledge, the Tourist Park also provided support in the form of provision of accommodation, drinks, food and transport for the emergency services staff and volunteers.141

125. DBCA indicated that their local staff in Shark Bay were only advised by police of Mr Buske’s death on 11 November 2019. The DBCA District Manager, Mr Stephen Nicholson, says he then travelled from Shark Bay to Mount Augustus via Police AirWing in order to assist emergency services with some local knowledge of the area. By the time he arrived, Mr Buske had been found, but he did walk the trail with 141 Exhibit 3, Tab 11.

[2022] WACOR 29 police to look at where Mr Buske might have left the trail and discuss issues surrounding the incident.142 Mr Nicholson also travelled to Burringurrah Community at a later time to participate in a debrief that Superintendent Beer arranged.143

CAUSE AND MANNER OF DEATH – MR BUSKE

126. A post mortem examination was made of Mr Buske’s body by Forensic Pathologist, Dr Vagaja and Anatomical Pathology Registrar, Dr Grewal on 15 November 2019 after Mr Buske’s body had been transported to Burringurrah Community by car and then flown to Perth to the State Mortuary. No significant injuries were detected but there was widespread established decompositional changes. In light of the presence of the decompositional changes, due to the length of time that had elapsed from death and the circumstances in which Mr Buske’s body was found, it was noted that the cause of death might be unascertainable.144

127. However, there was evidence present of significant scarring in the heart muscle involving the left ventricle, and microscopy confirmed the presence of coronary artery disease which was focally severe. Dr Vagaja explained that atherosclerotic heart disease is a disease of the heart, which arises as a consequence of narrowing of the coronary arteries that feed the heart muscle. As they progressively become narrower, the heart muscle becomes chronically short of oxygen and nutrients and starts to re-model in a way that cells become bigger, or it starts to be replaced by scar tissue. The significance of this, is that it becomes and abnormal tissue and can predispose an individual to the sudden abnormal beating rhythm of the heart.145

128. The forensic pathologists were given medical information that Mr Buske had some symptoms of cardiac disease investigated by a cardiologist in 2013, some time before he travelled to Australia. The testing found Mr Buske intermittently had abnormal rhythms in the heart, which was an indicator his heart was not functioning properly at that time, and he also had an abnormal motion of the heart muscle, which can be a result of the re-modelling described above. He had also been diagnosed with sleep apnoea, which increases the risk of cardiac failure.146

129. These findings were considered within the context of what was known about the circumstances surrounding Mr Buske’s death while exposed to a hot environment.

Placing a person with significant chronic disease, such as heart disease, in a situation of high physiological stress, increases the likelihood that they will suffer an adverse event. In that sense, exposure to extreme heat is a well-recognised risk factor for sudden death in the setting of underlying cardiac disease. Taking together the environmental exposure with Mr Buske’s known heart disease, enabled Dr Vagaja to reach a conclusion as to the cause of death.147 142 T 332; Exhibit 3, Tab 3.

143 T 332.

144 Exhibit 1, Tab 23.1.

145 T 75 – 76.

146 T 77 - 78.

147 T 77 – 79; Exhibit 1, Tab 9 and Tab 23.1 – 23.2.

[2022] WACOR 29

130. At the conclusion of all the post mortem investigations considered relevant by Dr Vagaja, she formed the opinion the cause of Mr Buske’s death was atherosclerotic heart disease in a man with environmental exposure.148

131. At the inquest, Dr Vagaja gave evidence that following her determination of Mr Buske’s cause of death, she had an opportunity to view Dr Luckin’s report prepared for this inquest (which she had available to her when she did the post mortem for Mrs Pollard). After viewing the additional information provided by Dr Luckin about the environmental risk factors, it confirmed Dr Vagaja’s view that Mr Buske was predisposed to a fatal cardiac event when climbing Mount Augustus.149

132. Dr Luckin provided an opinion in his report that Mr Buske’s death was consistent with dehydration and hyperthermia. Dr Luckin noted that Mr Buske had flown to Australia from the cold of Germany in late autumn, and had only been in Australia four full days when he attempted the Mount Augustus hike, so he had not had adequate time or exposure to acclimatise to the environmental conditions and his ability to cool by sweating would have been very limited. The maximum temperature that day was 41°C and he did not start the hike until 9.00 am, meaning he would have been walking towards the hottest part of the day. Based on the known circumstances, Dr Luckin identified Mr Buske’s specific risk factors were:150

• the fact he was not acclimatised;

• inadequate fluid intake;

• lack of understanding of local climatic conditions;

• he walked during the hottest part of the day;

• inappropriate clothing and footwear (noting the absence of hat at the place of death, although he had been wearing one earlier); and

• his age.

133. Dr Luckin noted that the fact Mr Buske was found off track was consistent with the confusion and decreased mental capability of severe hyperthermia.

134. Dr Luckin emphasised that Mr and Mrs Buske were experienced walkers, capable and intelligent people, spoke good English and had researched the Mount Augustus walk and read and understood the signage. They had made attempts to prepare themselves for their ascent to the summit of Mt Augustus, including taking with them over 10 litres of water, wearing hats and proceeding at a slow pace and taking lots of rests, but it appears that the harsh conditions and extreme heat had a greater deleterious effect on Mr Buske than they expected. The implication is that the current literature and signage at that time did not adequately warn and prepare them, as overseas visitors, for the inherent dangers of what they were attempting.151

135. Mr Buske died from the effect of environmental exposure on the background of his underlying cardiac disease. Although his heart disease played a role in his death, Dr Vagaja confirmed that in her opinion, the “environment did play a significant role” in 148 Exhibit 1, Tab 23.2.

149 T 75, 80.

150 Exhibit 3, Tab 13.1, pp. 14 – 15.

151 Exhibit 3, Tab 13.1, p. 15.

[2022] WACOR 29 his death.”152 Accordingly, I find that the manner of death was by way of accident and not natural causes.

MR AND MRS POLLARD

136. Anne Maree Pollard (known to her family and friends as Maree) was married to Lance Pollard and they had two sons. At the time of her death, they lived in the suburb of Hamersley in Perth. Mrs Pollard worked as a bookkeeper and her husband is a police officer with the WA Police. Mr and Mrs Pollard were keen hikers. Over the years they had walked together on most of the Bibbulmun track, the Kalbarri loop walk and a number of hikes in North America, including at the Grand Canyon. Their most recent hikes had been a number of trails in Northern California and Oregon in

2019. Those walks were each on average about two hours in duration.153

137. Mr Pollard has diabetes, having been diagnosed in 1999, and is on an insulin pump.

His diabetes had not affected his ability to hike with his wife, but other health issues had impacted on his ability to walk long distances in more recent years and in 2020 had not exercised much. In comparison, Mr Pollard believed Mrs Pollard was generally fit and well for her age of 53 years. She cycled regularly on Saturdays in a group called the ‘High Rollers’ and would also sometimes ride during the week, as well as walking her dog for half an hour most days. Mrs Pollard had been diagnosed with a heart murmur some years before, but did not have any treatment or take any medication for the condition.154

138. Mrs Pollard did also take Methoblastin (methotrexate) tablets. She attended the Coolibah Medical Centre, and their records indicate that Mrs Pollard had been diagnosed with Polymyalgia rheumatica from 30 July 2018. This is an inflammatory disorder that can cause muscle pain and stiffness and is sometimes treated with Methoblastin. She was also prescribed an anti-inflammatory, Naprosyn, presumably to help with her muscular issues.155

139. Mr and Mrs Pollard usually travelled overseas ever year but, due to COVID19, in 2020 they decided to travel within Western Australia. Hiking at Mount Augustus had been on Mr and Mrs Pollard’s ‘bucket list’ for a long time so they planned a trip that included a visit to Mount Augustus. They both did research online and formulated a plan to travel to Meekatharra then head up to Mount Augustus for a couple of nights.

From there, they intended to drive on to Karijini National Park where they would meet up with Mrs Pollard’s sister. They then planned to journey back along the coast, visiting Exmouth, Kalbarri, Geraldton and Jurien Bay before heading home to Perth.156

140. Mr Pollard remembered that before they left for the trip, they looked at a couple of websites and YouTube sites about Mount Augustus to find out what they needed to take with them. He believes he looked at information on the Parks and Wildlife website. From the research that he did, Mr Pollard could not recall having any

152 T 80.

153 Exhibit 1, Tab 28.

154 Exhibit 1, Tab 28.

155 Exhibit 1, Tab 28.

156 Exhibit 1, Tab 28.

[2022] WACOR 29 concerns about going to Mr Augustus. He did not remember seeing any information about needing lots of water or about any of the dangers of walking along Mount Augustus. Mr Pollard indicated in his statement his main priority was just going to see it, and he didn’t have any strong feelings about walking to the top of Mount Augustus. Mrs Pollard, on the other hand, was keen to walk up the mountain.157

141. On Friday, 11 September 2020, Mr and Mrs Pollard collected a 4WD Toyota Prado hire car to drive on the journey. They left Perth on Saturday morning, 12 September 2020 and drove straight to Meekatharra. They booked into a hotel and spent the night in Meekatharra. On Sunday, 13 September 2020, Mr and Mrs Pollard left Meekatharra at 9.00 am and drove to the Mount Augustus Tourist Park. The journey took about five hours and they arrived later that afternoon. After checking into their accommodation at the Tourist Park, they had a beer to celebrate their arrival then drove around and watched the sunset together. Mrs Pollard had read about how the sunset was reflected in colour changes on the rock and they were keen to see it. They shared a bottle of wine together whilst watching the sunset, then returned to their room and ate dinner. They each had a glass of wine at dinner but then didn’t drink any more alcohol as they were conscious of the fact they would be walking the next day. Mr Pollard recalled this day had been hot, but not excessively hot.158

142. Before going to bed, Mrs Pollard made up wraps to take for their lunch the next day and they filled up a 3 litre water bladder. They also had two 1 litre water bottles and two 750 ml water bottles. All of these items were put in the fridge overnight.159

143. Mr and Mrs Pollard woke up at around 6.00 am on Monday, 14 September 2020.

They both ate cereal for breakfast and each drank a 750 ml bottle of soda water, which was part of their regular morning routine. They signed the visitor book in the Tourist Park office at 6.30 am indicating that they intended to take the summit trail and go to Cattle Pool trail.160 They then drove to the Flintstone carpark. Mr Pollard recalled the mountain was still in shade and he did not think it was excessively hot at that time.161

144. They planned to walk the summit trail as far as they could. Mr Pollard wasn’t sure he would be able to make it all the way to the summit although he was going to try. If he felt unable to reach the summit, the plan was for Mrs Pollard to walk to the top by herself. They were aware there were two tracks to the summit, and one was harder than the other, so they chose the summit trail, which was easier. Mr Pollard believes they set off on the summit trail at about 7.00 am.162

145. As soon as they started walking, Mr Pollard observed that the track was “hard going and difficult”163 and much harder than he had expected. He was, however, happy with the way the track was signposted. They stopped often on the walk up, and each 157 Exhibit 1, Tab 28.

158 Exhibit 1, Tab 28.

159 Exhibit 1, Tab 28.

160 Exhibit 2, Tab 3.2.

161 Exhibit 1, Tab 28.

162 Exhibit 1, Tab 28.

163 Exhibit 1, Tab 28 [72].

[2022] WACOR 29 time Mr Pollard checked his blood sugar levels. He had his insulin pump with him and felt confident he could keep his levels right.164

146. Their first stop was after walking about 45 minutes. Mr Pollard said he was feeling alright at this time, although he was sweating. Mrs Pollard had been walking in front of him for most of the way and she did not appear to have any issues at all with the walk. Mr Pollard checked his blood sugar levels and was happy with the levels. Mrs Pollard asked him if he wanted to turn around at that stage, but he felt that he could continue walking, so they made a mutual decision to push on.165

147. They kept walking up the summit trail and had minor breaks every now and then, often to catch their breath after a steep hill or hard part of the track. Just before the junction of the summit and Gully Trail, Mr Pollard passed a couple of people going down from the summit. It was a man and woman, and Mr Pollard estimated they were both older than him. They had a short conversation and then the other people continued walking down while Mr Pollard continued his ascent. Shortly after, they reached a junction of the two trails and stopped. This was most likely at the 450 metre mark. Mr Pollard told Mrs Pollard he was going to stop walking at that point and wasn’t going to go any further towards the summit. He checked his phone at that time and noted it was 10.30 am, so they had been walking for about three and a half hours.166

148. Mrs Pollard said she believed the summit was only a kilometre away, so she would continue to walk and hopefully reach the summit. Mr Pollard wasn’t certain where she had got her information, but thought it was possible it had come from the two people they had passed. Mr Pollard found some shade and sat down to wait, while Mrs Pollard continued walking up towards the summit. After a short time, another couple came down from the summit. This couple, a man and a woman also, appeared younger than Mr Pollard and he thought they looked pretty fit. He saw them take the harder, Gully Trail, as they continued on with their descent.167

149. Sometime later Mr Pollard saw another man walking down the mountain on his own.

Mr Pollard had seen this man previously, when they first commenced their walk, as he had walked past them as he headed up the mountain. Mr Pollard asked the man if he had seen his wife and the man replied that he had. He didn’t make any other comment about Mrs Pollard. They had a discussion about the two different tracks and the man then stated he would walk back via the harder gully track. It was between midday and 12.30 pm at this time and Mr Pollard had begun to wonder why Mrs Pollard was taking so long. He thought that she should have been back by then, if she only had to walk another kilometre, and he began to be concerned.168

150. Mr Pollard had recovered from his tiredness at this stage and was feeling good, so he decided to walk to the summit to find his wife and make sure nothing had happened to her. Mr Pollard started walking up the trail and called out to Mrs Pollard while he walked. He started to become stressed and worried for his wife as he walked, so he believes he probably walked faster than he normally would. After walking for about 164 Exhibit 1, Tab 28.

165 Exhibit 1, Tab 28.

166 Exhibit 1, Tab 28.

167 Exhibit 1, Tab 28.

168 Exhibit 1, Tab 28.

[2022] WACOR 29 half an hour he found his wife. He asked her why she had been gone so long and she advised that it was further than she thought, certainly longer than a kilometre, but she had eventually managed to reach the summit. Mrs Pollard told her husband she had phone reception at the top of the mountain.

151. At that stage, Mr Pollard was hot and sweating. He could tell that he was in heat distress, as he had experienced heat stress in the past when he was in the army and knew what it felt like. He was aware that he needed to get back down the mountain as a priority. They started walking down and Mr Pollard began to experience significant discomfort. He felt like his shorts were burning against his legs, so he removed his shorts and left them on the track. He was very distressed at this stage and told his wife that he couldn’t go on any longer and needed to rest. He felt exhausted and hotter than he ever had in his life. Mrs Pollard found him some shade, where he sat. Mr Pollard didn’t have the mental capacity to check his blood sugars at this stage and felt he couldn’t make any rational decisions. They had both drunk most of their water supply by this stage, drinking about the same amount each, and they had very little water left, even though Mr Pollard had been trying to ration some of it for the trip down.169

152. Mrs Pollard eventually decided he should stay where he was and she would go and get help. She took Mr Pollard’s backpack, as it had the hire car keys in it, and began walking down the trail. He was not very coherent at this stage due to the heat and lack of water but remembered watching her walk away. Mr Pollard waited for a considerable period of time. Initially, when no one came, he thought the rescuers might be waiting until it got cooler before coming up to help him. However, as it got later, and the sun started going down, he realised he would have to start walking down as help was not arriving. He had no water left at this stage. He remembered reading somewhere that you can drink your own urine, so he urinated into the empty water bladder then drank part of it in his desperation.170

153. Mr Pollard had been experiencing the same burning sensation from his socks that he had been feeling from his shorts, so he removed his socks and walked just in his shoes as he started down the mountain. He drank the rest of the urine in the bladder on the way. Mr Pollard eventually found another place to stop, and he then took off his boots and t-shirt and hat for a time. While resting, he urinated into the empty bladder again and drank some more of it. He then put his hat, t-shirt and boots back on and started walking again. Mr Pollard could see the carpark in the distance and could still see the markings, so he knew he was on the right path. He eventually found a seat that he had passed on the way up, which reassured him that he was making progress. However, it then got dark and he could no longer see anything. He was stumbling around and started to worry he had lost the trail. He eventually realised he was still on the track, but by this stage he was too exhausted to walk. He was burning with thirst but had no urine left in his body, and he was unable to stand up, despite trying.171 169 Exhibit 1, Tab 28.

170 Exhibit 1, Tab 28.

171 Exhibit 1, Tab 28.

[2022] WACOR 29

154. At this stage, in desperation, Mr Pollard started to yell out for help. He heard voices behind him and saw a light, so he yelled out again. Eventually, some boys responded and Mr Pollard called out to them that he was lost and had no water.172

THE DISCOVERY OF MR AND MRS POLLARD

155. Sky Nash was travelling around Western Australia and had stopped to surf in the Gnaraloo area in September 2020. He met up with some other surfers, including Harry Wellington and Tobias (Toby) Coffin, and after some discussion they arranged to go in a group to visit Mount Augustus. They left to drive to Mount Augustus in a convoy on Saturday, 12 September 2020, stopping to camp along the way. On Sunday, 13 September 2020, some of the group decided to head back, but Toby Coffin, Harry Wellington and Sky Nash .173

156. They drove from the Kennedy Ranges towards Mount Augustus and noticed that the day was very hot. Sky had previously been in the army and toured Iraq and Africa, and he believed the temperatures he experienced this day were hotter than anything he had experienced in Africa. They stopped for a swim on the way, due to the heat, and eventually arrived at the Mount Augustus Tourist Park in the mid-afternoon.

They purchased some fuel and went into the store, where they looked at a large map of the Mount Augustus area. After looking at the map, they decided on some short walks to do that afternoon.174

157. The three men drove to Mount Augustus and completed one short walk. They then decided not to complete a second short walk as it was too hot. At this stage, they decided that they would sleep the night in the Flintstone carpark so that they would be able to start the Summit Walk very early the next day, when it was cooler, and hopefully be back in the car by 8.00 am.175 When they arrived at the Flintstone carpark between 5.00 pm and 6.00 pm, they saw the Pollards’ Prado hire car parked in the carpark. They discussed the fact that it was odd that there was no one with the vehicle.176

158. After parking, the three young men set up a temporary camp to relax for the evening.

It was still hot and the air was dry but calm. While it was still light, they heard a male voice calling out, but it was too distant to hear the actual words. Sky assumed it was the person returning to the Prado and thought he was talking to other people in his party, so he was not concerned. They started to make some dinner and then heard the male voice again, but still thought the male was talking to someone else. At this stage, Sky and his friends decided to play a game where they called out and listened for echoes. The first two young men called out, but when it came to Sky’s turn he heard the unknown male call out instead, asking for help. Sky yelled out, “Are you ok?” and heard in response, “No, I’m lost. I have no water, I need help.” This was the first time anyone was aware that Mr and Mrs Pollard were lost out there and needed help.177 172 Exhibit 1, Tab 28.

173 Exhibit 1, Tab 29 and Tab 30.

174 Exhibit 1, Tab 29.

175 Note there is no camping permitted at Mt Augustus National Park.

176 Exhibit 1, Tab 29.

177 Exhibit 1, Tab 29.

[2022] WACOR 29

159. Sky called back to Mr Pollard to wait where he was and they would come and find him. It was just gone dark at this time and there was no moon. Toby used his mobile phone as a torch and began to run up the track. Sky grabbed a torch and a 1 litre water bottle and followed him, while Harry stayed in the carpark as a safeguard.

They stopped after running about 150 metres and Sky called out to Mr Pollard again to try and gauge his location. Mr Pollard responded and Sky could tell by the sound of his voice that they were now closer to Mr Pollard, but it appeared he was slightly off the track. Sky left the track and walked in the direction of Mr Pollard’s voice, calling out to him a few times to help locate him. Sky estimated they found Mr Pollard about ten minutes after they had left the carpark and started looking for him.178

160. Mr Pollard was located about 300 metres from the carpark on top of a small cliff.

Sky had to climb up the cliff to reach Mr Pollard. He found Mr Pollard at about 7.30 pm. Mr Pollard was sitting on the ground wearing only his underpants and shoes without socks. He had a small empty camelback water bag next to him and a hiking stick. He appeared weak and possibly delirious. Mr Pollard told Sky he had resorted to drinking his own urine, which impressed on Sky the seriousness of the situation.

He immediately gave Mr Pollard his bottle of water, which Mr Pollard drank very quickly. Mr Pollard then asked if they were the search party sent to look for him. Sky explained they were not, and had simply been in the carpark by chance and heard him calling out. At this point Mr Pollard became distressed as he was immediately very concerned for his wife, who had left to get help.179

161. Sky asked Mr Pollard when he last saw his wife and around this time he heard a sound like a mobile phone tone. He asked Mr Pollard if he had a phone and, if so, why he hadn’t rung for help. Mr Pollard explained he and his wife had swapped backpacks so his wife had his phone in his backpack with her, and the phone they could hear must be his wife’s phone that was in her backpack that he held. They retrieved Mrs Pollard’s phone from the backpack and noted it did not have a signal but did show a message on the screen.180

162. Mr Pollard explained he had last seen his wife around midday when she had left him with their small remaining amount of water and returned down the mountain to get help. Mr Pollard was calling out his wife’s name while relating what had happened Sky became increasingly concerned for her welfare. They were unable to move Mr Pollard as he did not have the strength to stand up, so Sky decided to return to the carpark to ask Harry to go and get help and also to look for Mrs Pollard. Sky left Mr Pollard and Toby together and headed towards the carpark. He knew his torch was going to run out of battery soon, so he started running in the direction of the carpark.181

163. About one minute after leaving Mr Pollard and Toby, Sky saw a hiking stick on the ground and immediately stopped running. He shone his torch around and saw Mrs Pollard lying on her back on the track about three metres away from the hiking stick.

178 Exhibit 1, Tab 29.

179 Exhibit 1, Tab 29.

180 Exhibit 1, Tab 29.

181 Exhibit 1, Tab 29.

[2022] WACOR 29 She was fully clothed, including still wearing her hat and sunglasses, and had her backpack on. Sky could see a sign right next to her that signposted the start of the summit and Gully Trails, as well as the path to Flintstone rock.182

164. Sky was initially pleased to see Mrs Pollard, thinking that he would be able to help her, but as he unsuccessfully tried to get a response from her, he came to realise she was deceased. Due to his previous experience in the military, Sky had seen deceased persons before. Sky made an assessment that Mrs Pollard had been deceased for some time before he found her. He estimated he found her body at about 8.00 pm.183

165. Sky took a moment to absorb the situation, then decided to return to Mr Pollard and make sure that Toby was safe with him, as he wasn’t sure what had happened. Sky managed to get Toby to come out of earshot and whispered to him that he had found Mr Pollard’s wife deceased. Sky had broken his thong, so they agreed Toby would return to the carpark as he had footwear and Sky would remain with Mr Pollard.

After Toby left for the carpark, Sky tried to keep a conversation going with Mr Pollard to distract him from the situation. Mr Pollard continued to call out intermittently to his wife. Sky did not tell him at that stage that he had found his wife.184

166. Toby ran back to the carpark. On the way, he came across Mrs Pollard’s body. He checked her and confirmed she had no pulse and felt stiff and cold. He then continued on to the carpark and told Harry that they had found a man with severe heat stroke and a female who was unresponsive. Toby asked Harry to go and get help. Harry got in his car and drove to the Tourist Park. When he arrived at the Tourist Park, he went to the managers’ house and spoke to the occupants. He explained the situation and asked if they could help. A female said words to the effect, “what do you want us to do about it?”, but a male at the house said he would call someone. At the same time, another guest at the Tourist Park, Sheena Davies, overheard and identified herself as a nurse.185 I note it seems the female at the Tourist Park also made a call to SJA and kept in contact with SJA to try to get an emergency medical response to the area.186

167. Sheena had come to the Tourist Park with her mother, partner and children the night before. They had been hiking in the park around lunchtime to early afternoon on 14 September 2020 and had noticed Mr and Mrs Pollard’s hire car in the Flintstone carpark when they completed the Flintstones trail at about 2.30 pm. It had been very hot at that time. Sheena and her partner made a note of the registration plate as they had realised that whoever belonged to the vehicle must have been hiking in the heat so they thought, out of an abundance of caution, it was worth noting their details.

Sheena and her family then returned to the Tourist Park and settled in for the night.

They had eaten their dinner and were cleaning up at about 7.00 pm when, Sheena and her mother, Ms Davies, heard Harry driving quickly into the Tourist Park and could tell something was wrong, so they followed him and overheard his conversation with 182 Exhibit 1, Tab 29; Exhibit 2, Tab 1 and Tab 3.1.

183 Exhibit 1, Tab 29.

184 Exhibit 1, Tab 29.

185 Exhibit 2, Tab 21.

186 Exhibit 3, Tab 21.

[2022] WACOR 29 the people at the manager’s house. Sheena and Ms Davies approached Harry and offered to help.187

168. Harry explained what he knew about Mr and Mrs Pollard and Sheena and her mother offered to follow him back to Mount Augustus. They went and found Sheena’s partner, Mr Davis, and arranged for someone to watch over the children. Sheena also collected some more water and a first aid kit, then drove with her partner and mother to Mount Augustus in convoy with Harry.188

169. Toby had returned to where Sky and Mr Pollard were waiting, bringing some more water with him for Mr Pollard. Toby and Sky discussed Mrs Pollard’s situation. Sky then left to return to the carpark and obtain some more water and some hydrolyte powder from his first aid kit, as well as some other torches and some muesli bars. He noticed he felt dehydrated and drank some water himself before returning to Mr Pollard and Toby.189

170. As he was walking back from the carpark Sky heard vehicles arriving, so he turned around and made his way back towards the carpark to meet the new arrivals. The people arriving had first aid equipment and Sky understood one of them, Sheena, was a nurse. Sky explained the situation, including the fact he had not yet told Mr Pollard that his wife was deceased.

171. They stopped next to Mrs Pollard, who was approximately not far up the trail from the carpark. Sheena checked Mrs Pollard for any vital signs before confirming she was deceased. They got out an emergency blanket from the first aid items and used it to cover Mrs Pollard, placing some rocks around it to make sure it remained in place to protect her body from the elements. They then continued up the path to meet Mr Pollard and Toby. Ms Davies had checked her watch so she was aware they confirmed Mrs Pollard was deceased at 7.57 pm and then continued on and came across Mr Pollard at 8.04 pm. She estimated they were only about 150 to 200 metres apart.190

172. On arrival, Sky gave Mr Pollard the hydrolyte water combination he had prepared.

Sheena then did a quick vital sign check of Mr Pollard and noted his heart rate was elevated and his oxygen levels seemed fine. He appeared visibly dehydrated and was not sweating, despite the air temperature being warm. They gave him some ice packs to put on his body to cool him down. They group then discussed the situation and came up with a plan, which involved some of the group staying with Mr Pollard and the others returning to the Tourist Park to get more help and to notify emergency services. Mr Pollard advised at this stage that he was a police officer. The group who stayed with Mr Pollard made sure he continued to rehydrate. They all agreed not to tell him about his wife at this stage as they were worried he might go into shock.191

173. While waiting with Mr Pollard, Ms Davies became aware that Mr Pollard was a diabetic. He said that he didn’t have his insulin tester as he had swapped backpacks with his wife. Ms Davies went and found his backpack and located the insulin pump 187 Exhibit 2, Tab 1.

188 Exhibit 1, Tab 30 and Tab 31; Exhibit 2, Tab 21.

189 Exhibit 1, Tab 29.

190 Exhibit 1, Tab 29; Exhibit 2, Tab 21.

191 Exhibit 1, Tab 29; Exhibit 2, Tab 21.

[2022] WACOR 29 inside, which she then gave to him. It hung around his neck and attached to his side.

At that stage, Mr Pollard still seemed confused and disorientated.192

174. Sheena and her partner returned to the Tourist Park and contacted emergency services from the managers’ house as their mobile phones had no reception. The Tourist Park managers had already contacted emergency services but Sheena spoke to SJA officers and was able to provide some more detailed medical information.

The SJA operator confirmed that RFDS would be asked to come to help and the Carnarvon Police Station had been notified, but there was no immediate help on the way. The operator provided some advice as to what first aid treatment they should provide to Mr Pollard in the meantime and that it would be best if they could get him back to the Tourist Park. The operator also advised they should not move Mrs Pollard, but someone should stay with her body and Mr Pollard should be told of her death. While still at the Tourist Park, Sheena also spoke to the nurse from Burringurrah Community, Marie, who advised she was trying to get permission to leave the Burringurrah Community to come and help.193

175. After about an hour Sheena and her partner returned to the carpark with a stretcher provided by the Tourist Park managers and some more food and water for Mr Pollard. They advised they had also spoken to police in Carnarvon who had directed them to leave Mrs Pollard in situ, with someone to remain guard over her to ensure her body was not disturbed, and to let Mr Pollard know that she had died.194

176. When they reached Mr Pollard, Sheena explained to Mr Pollard that his wife had died and allowed him to absorb the news. He was understandably upset but didn’t appear able to cry tears due to his level of dehydration. They spent some time comforting him and then advised Mr Pollard they needed to get him off Mount Augustus. Ms Davies bandaged his feet, which were badly blistered as he had been wearing his boots without socks. The socks were in his backpack, so she put them back on him and helped him to put his boots back on. Mr Pollard indicated he felt he was able to walk with some assistance, so they gave him his hiking stick and helped him walk. On the way back down, Mr Pollard started to sweat and was crying, and he also stopped to urinate, which reassured them that he was rehydrating. They passed Mrs Pollard’s body on the way and Mr Pollard stopped and took some time to say goodbye before they all returned to the carpark.195

177. As they reached the carpark, an ambulance pulled in. It was Marie, the nurse from the Burringurrah Community that Sheena had spoken to earlier, and Marie’s husband. They took over the care of Mr Pollard and took him back to the Tourist Park for treatment. After Mr Pollard left, Sky, Toby and Harry took on the responsibility of watching over Mrs Pollard’s body for the remainder of the night, until the first police officers arrived to relieve them at about 4.30 am on 15 September 2020.196

178. Sergeant Anntoinette Cashmore and First Class Constable Hawke had been notified of the incident at about 8.30 pm the previous night and had left Carnarvon Police 192 Exhibit 2, Tab 21.

193 Exhibit 2, Tab 1.

194 Exhibit 1, Tab 29; Exhibit 2, Tab 1.

195 Exhibit 1, Tab 29; Exhibit 2, Tab 1 and Tab 21.

196 Exhibit 1, Tab 29.

[2022] WACOR 29 Station at approximately 9.30 pm. They drove all night and arrived at the Flintstone carpark at approximately 4.30 am on Tuesday, 15 September 2020. They saw Mr and Mrs Pollard’s hire car in the carpark area, and also Harry and Sky’s cars parked there. A short time after the police officers arrived, they were joined by representatives from the Gascoyne Funeral Home. Sgt Cashmore and 1/C Constable Hawke walked up the summit trail and came across Sky, Harry and Toby, who pointed them to where Mrs Pollard’s body was located, still covered by the blanket.

Sgt Cashmore took photographs of Mrs Pollard in situ and noted that nearby was a small bag and hiking stick. There were three empty water bottles and two empty muesli packets in the bag. Mrs Pollard also had a bag on her back that contained an iPhone. Mrs Pollard was fully clothed and had a fresh graze to her right knee and right elbow, but there was no blood near her body or on the trail.197

179. It was indicated at the inquest by Inspector Cox that Mrs Pollard’s body was found within 30 to 40 metres of the carpark, just at the start of the trail. When found, Mr Pollard was only a short distance further up the trail, about 20 metres away from his wife’s body, although that would not have been apparent to Mr Pollard in the dark.198

180. After taking sufficient photographs of Mrs Pollard and the scene, the police officers carried Mrs Pollard from the mountain with the assistance of the funeral contractor.

The funeral contractor then took Mrs Pollard to Carnarvon and the police officers went to the Tourist Park and spoke to Mr Pollard. Later that day, Mr Pollard was taken in the Burringurrah ambulance to the Burringurrah Community air strip and then flown to Carnarvon by the RFDS. The police took steps to notify Mrs Pollard’s sister, who they were supposed to be meeting in Karijini that day, and the Pollards’ sons and Mrs Pollard’s parents in Perth.199

CAUSE AND MANNER OF DEATH – MRS POLLARD

181. A nurse at Carnarvon Hospital formally certified Mrs Pollard’s death during the afternoon of 15 September 2020.200

182. A post mortem examination of Mrs Pollard was conducted by Forensic Pathologist, Dr Vagaja and Forensic Pathology Registrar Dr Ong on 21 September 2020 after Mrs Pollard’s body was transported to the State Mortuary in Perth. Due to the delay between her death and the post mortem examination, as well as the environmental exposure which can accelerate the decomposition process, widespread post mortem decomposition changes were noted, particularly to the upper torso. Scattered superficial soft tissue injuries were also noted, which were thought may have indicated that Mrs Pollard lost her balance or coordination and was unable to walk properly or maybe fell at some stage. There were no significant injuries observed.

Mrs Pollard had a BMI in keeping with obesity, which is a risk factor for heatstroke, an enlarged heart and mild to moderate coronary artery atherosclerosis. Following the initial examination, the cause of death was undetermined, so further 197 Exhibit 2, Tab 2.

198 T 18 – 19; Exhibit 4A.

199 Exhibit 2, Tab 4.

200 Exhibit 1, Tab 27.

[2022] WACOR 29 investigations were performed, including microscopy, blood biochemistry, virology, toxicology and immunology testing.201

183. The toxicology analysis found therapeutic levels of Naprosyn (naproxen) but did not detect methotrexate. Naproxen is a very common non-steroidal anti-inflammatory medication, which does not cause sedation and would have been therapeutic for her musculoskeletal condition. There was nothing to suggest it played any role in the death. Neuropathology found no significant abnormality.202 Mrs Pollard was also found to have some alcohol present in the vitreous humour sample, which is protected from decomposition and suggested that Mrs Pollard had consumed alcohol the night before, as reported, even though she recorded no alcohol in her blood.203 It is relevant only as alcohol consumption is another risk factor for heatstroke, as explained by Dr Luckin.

184. Dr Vagaja also undertook some particular testing to rule out the possibility that Mrs Pollard had succumbed to a snake bite or anaphylactic reaction to a bee sting, given the circumstances in which she was found on a nature trail with no witnesses to the event. The forensic pathologists found no evidence that pointed to either of these events occurring.204

185. As well as the additional testing, Dr Vagaja and Dr Ong were provided with information by Inspector Cox about the circumstances surrounding Mrs Pollard’s death, and information from Dr Luckin about the significant risk factors for environmental hyperthermia present in this case.

186. Dr Luckin considered the risk factors for Mrs Pollard, who I note was significantly younger than Mr Buske and the Greens, as:205

• Obesity (BMI 33.6);

• Inadequate fluid intake, noting she had only 3 litres of empty water bottles with her, which was insufficient to prevent dehydration and death;

• Clothing which exposed her arms and legs to direct and reflected heat; and

• Continuing alone when Mr Pollard needed to stop and rest, which is contrary to the general advice to never walk alone.

187. Based upon the results of the post mortem examination and ancillary investigations, and considered within the context of the known circumstances leading up to the discovery of Mrs Pollard’s death and the additional expert information provided by Dr Luckin, Dr Vagaja and Dr Ong considered it was most plausible that Mrs Pollard sustained heat stroke due to environmental exposure at high temperatures, with concurrent prolonged physical activity and dehydration, leading to cardiovascular collapse and death. The cause of death was given as heat stroke (environmental exposure).

201 T 68, 72; Exhibit 2, Tab 5.1.

202 T 69; Exhibit 1, Tab 5.

203 T 72.

204 T 70 – 71.

205 Exhibit 1, Tab 13.1, p. 16.

[2022] WACOR 29

188. Dr Vagaja explained at the inquest that for our bodies to function properly, we need to be within a healthy range of body temperature. When it is too high or too low, our body tissues start to deteriorate, enzymes, which perform a lot of living functions, start to malperform or fail and the functions of life cannot be supported. When it reaches a certain tipping point, it cannot be reversed. Heat stroke is a type of hyperthermia or abnormally high body temperature. It can be caused by exposure to the environment, or can arise as a result of exertion (known as exertional heat stroke). It is best diagnosed when it is observed directly, particularly with a body temperature being taken at the time, but in Mrs Pollard’s case, the forensic pathologists felt confident, based upon the information available, that she had died as a result of the environmental exposure. In effect, her body temperature became critically high due to the effects of the very hot environments she was exposed to while walking the Summit Trail. 206 I accept and adopt the forensic pathologists’ opinion as to the cause of Mrs Pollard’s death.

189. The police investigation found no evidence to suggest that any other person was involved in Mrs Pollard’s death. There is nothing to suggest Mrs Pollard’s death was caused by any underlying natural condition. Mrs Pollard embarked on the Summit Walk that day under the mistaken belief that she was fit and well enough to undertake it safely and manage the conditions. I note that, like Mr and Mrs Buske, the Pollards were experienced walkers and had researched the Mount Augustus walk extensively beforehand. Once again, Dr Luckin noted that the implication is that the current literature at the time, across a spectrum of different sources, did not adequately warn and prepare Mr and Mrs Pollard (as visitors from Perth) to the risks of Mount Augustus, and how they should plan their journey.207 The harshness of the conditions that day, and the challenging nature of the walk, were greater than Mr and Mrs Pollard anticipated and Mrs Pollard succumbed to heat stroke. I find that the manner of Mrs Pollard’s death was by way of accident.

190. Dr Luckin noted that Mr Pollard was extremely fortunate in receiving assistance and water from two young boys who found him at night, which no doubt saved his life. I note that Mr Pollard also possessed good survival skills knowledge, that he utilised helped him survive.

MR AND MRS GREEN

191. Brian Green and Thelma Green were married and lived together in Maida Vale. They had adult children, two sons and one daughter. At the time of their deaths, Mr Green was 70 years of age and Mrs Green was 66 years of age. Mr Green had worked for the Main Roads Department as a soil scientist and Mrs Green was a registered nurse before they retired. They had met in Geraldton and spent a lot of time in regional towns such as Meekatharra, Geraldton and Newman over the years, working and travelling. Both Mr and Mrs Green were moderately fit for their age, engaging in regular daily exercise. Mr Green trained at a gym and played golf and walked regularly and Mrs Green did weight training at home and also walked regularly.208

206 T 66.

207 Exhibit 3, Tab 13.1, p. 16.

208 Exhibit 2, Tab 15.

[2022] WACOR 29

192. Over the years, Mr and Mrs Green had also enjoyed hiking regularly, both overseas and in Australia. Their daughter, Lisa Green, considered them to have a reasonable amount of hiking experience and indicated that they researched all of their hikes prior to attempting them. She was aware they planned extensively for their visit to climb Mount Augustus, which included speaking with other people who had completed the Mount Augustus hike to find out what to expect, and researching the most optimal time of year to visit the area.209

193. Not much is known about Mr and Mrs Green’s arrival at the Tourist Park. The visitor log at the Tourist Park records an entry for Mr and Mrs Green indicating they were going to the summit trail on 15 September 2020. No time is listed for their departure.

I note that Mr and Mrs Pollard’s entry was made above the Green’s entry, and the Pollards entry did not show any record that they had returned.210

194. The evidence indicates the Greens drove and parked in the Flintstones carpark, as their silver Prado was later found there. I infer from other evidence that they drove there on the morning of 15 September 2020 in order to walk the Summit Trail.

195. Jane Underwood had travelled from Perth to Mount Augustus with her partner Kim, arriving at the Mount Augustus Tourist Park on Sunday, 13 September 2020. On Tuesday, 15 September 2020, Ms Underwood and her partner hiked up Mount Augustus. They had parked in the carpark in the morning and walked up the Summit Trail. They appear to have been unaware of the events surrounding Mr and Mrs Pollard. Ms Underwood recalled the weather conditions were cool early, with a light cloud cover, as they were walking up to the summit. They reached the summit at approximately 9.00 am. However, when they descended later in the day the cloud cover had gone and the temperature had increased, and it was extremely hot and dry with little shade.211

196. During their descent, Ms Underwood and her partner came across another couple who were on their way up to the summit. They estimated this occurred about 30 minutes after they had started their descent, so around 9.30 am. As they crossed paths, both couples stopped and had a brief conversation. The other couple, who I am satisfied were Mr and Mrs Green, asked them how far it was to the summit. Ms Underwood mentioned at this time how hard the climb was, especially the last part of the climb to the summit. They also spoke about the beauty of the area and how nice the view was. Ms Underwood was predominantly speaking to Mr Green and she recalled being concerned that he was not wearing a hat and the couple only appeared to have one bottle of water. Each pair eventually went on their own way, with Ms Underwood and her partner continued their descent and reaching the carpark just before midday.212

197. Ms Underwood recalled that the hike to the summit had taken them longer than they had thought, at about six hours in total. They attributed the length to the fact that the last section of the climb to the summit was very hard, particularly given how hot it was due to the time of day. They had done some research beforehand in relation to 209 Exhibit 2, Tab 15.

210 Exhibit 2, Tab 3.2.

211 Exhibit 2, Tab 14.

212 Exhibit 2, Tab 14.

[2022] WACOR 29 the hike in the form of an information pamphlet obtained at the Tourist Park and reading the signs at Mount Augustus itself, but they did not feel in hindsight that this information had been sufficient to prepare them for the hike that they undertook.

They did, however, both enjoy the experience.213

198. The Greens’ daughter, Ms Lisa Green, received a text message from her mother at 10.58 am Western Australian time, on Tuesday, 15 September 2020. The message read, “On Mount Augustus now got reception … Walking down now.”214 She tried calling and then texted back a reply but Mrs Green did not respond and Ms Green assumed her mother no longer had reception.215

199. The next day, being 16 September 2020, was Mrs Green’s birthday. Her daughter sent her a text message wishing her a happy birthday. She did not receive a reply. It appears that sadly Mrs Green had died before her birthday and did not receive this message.

DISCOVERY OF MR GREEN AND SEARCH FOR MRS GREEN

200. Robert Kefford and his wife Jacqueline had travelled to Mount Augustus and booked into the Tourist Park on 15 September 2020. They arrived at about 4.00 pm and made camp for the night. The next morning, being 16 September 2020, they left the Tourist Park with their friends, John and Ruth Greenwood, in Mr Kefford’s car. The group of four drove to the Flintstones carpark, arriving at about 5.45 am. Their plan was to walk to the summit.216

201. Mr Kefford believes they started the walk at about 6.20 am. They had walked for about 35 minutes, travelling a distance estimated at about 1.6 kilometres, when Mr Kefford saw what appeared to be a deceased person on the trail. The person appeared to be male and was wearing blue shorts and a white shirt. As Mr Kefford approached him, he could see the man was pale and lifeless, and when he checked his right wrist he felt no pulse, and he felt very cold. Mr Kefford moved the body slightly to locate the person’s backpack and found some identification details for Thelma Green of Maida Vale. Mr Kefford and his friend took photographs of the information so they would not forget it. Mr Kefford also saw a hat near the person, which he placed on the body. It is not in issue that this was the body of Mr Green.217

202. Mr Kefford and his wife and friends discussed the situation to try to decide what to do. Mr Kefford and Mr Greenwood decided to walk up the trail to try and get a phone signal. They walked for about 20 minutes further up the trail and then Mr Kefford saw he had two bars on his Telstra phone. He tried several times to call ‘000’ but the call would not connect. Mr Greenwood had an Optus phone, but was equally unsuccessful. They eventually decided to walk back down. When they returned to their wives, they found they had been joined by James and Anne Carter.218 213 Exhibit 2, Tab 14.

214 Exhibit 2, Tab 15 [44].

215 Exhibit 2, Tab 27.

216 Exhibit 2, Tab 16.

217 Exhibit 2, Tab 16.

218 Exhibit 2, Tab 16.

[2022] WACOR 29

203. Mr and Mrs Carter had also arrived at the Mount Augustus Tourist Park during the afternoon of 15 September 2020. They had decided not to walk up to the summit that day as it was too hot. Instead, they settled in at the Tourist Park underneath the shade amongst the park’s sprinklers. They drove to Mount Augustus the next morning, arriving a little bit after the Keffords’ group, around 6.40 am. They observed two cars in the carpark, the white one belonging to the Keffords and another silver car, which we now know belonged to the Greens. They saw no other people in the carpark. They prepared themselves to start walking, noting the weather was cool and there was no wind at that time. After walking about one kilometre up the summit trail, they came across Mrs Kefford and Mrs Greenwood. It was about 7.30 am by this time. They advised the Carters that they had discovered a body on the trail and that their husbands were trying to get a phone signal to report the death. They were joined shortly after by Mr Kefford and Mr Greenwood, who explained they had been unable to get a signal.219

204. Mr and Mrs Carter offered to continue walking up the trail to see if they had more success getting a phone signal, and to see if anyone else was up there. The Keffords and Greenwoods would, in the meantime, return to the Tourist Park to ring the police.220

205. After returning to the carpark, one of the group wrote a note to advise that there was a body on the trail and left it on the silver Prado motor vehicle that they thought might belong to the body they had found. Mr Kefford looked inside the car to see if there were any other people inside, in particular a woman, given the name on the backpack Mr Green was found holding. Mr Kefford saw numerous items that appeared to belong to a woman, so the group reached the conclusion a woman was likely travelling with him.221

206. The Carters, in the meantime, had kept walking up the trail and passed Mr Green’s body, then continued up the trail further. They continually stopped and checked their phones for a signal. About 20 minutes after passing Mr Green’s body, Mrs Carter received an SOS signal on her spare Optus prepaid mobile phone, so she used it to call ‘000’ and request police assistance. The operator asked for her location, and Mrs Carter advised she was at Mount Augustus, which appeared to confuse the operator.

Mrs Carter repeated her location and explained there was a deceased male about a 60 minute walk up the summit trail. The operator asked for Mrs Carter’s number, but because it was a prepaid mobile with only an SOS signal, she was unable to provide it. The operator was having difficulty finding their location and understanding the situation, so Mrs Carter said she was talking fast and trying to get her message across quickly as her signal was not strong and she was worried it might drop out. The signal did, in the end, drop out and Mrs Carter was not able to finish her conversation with the operator.222

207. Mrs Carter was feeling wobbly and stressed after the call, and they noted that the path ahead looked hard, so they decided to stop climbing and return back down the 219 Exhibit 2, Tab 16 and Tab 17.

220 Exhibit 2, Tab 16 and Tab 17.

221 Exhibit 2, Tab 16.

222 Exhibit 2, Tab 17.

[2022] WACOR 29 summit trail to their car. On the way, they diverted off the track so that they would not need to pass Mr Green’s body again. It took Mr and Mrs Carter about an hour and a half to walk back down the summit trail to their car in the carpark. Although they had expected the walk down might be easier than their ascent, they found the way difficult due to having to be careful around loose rocks and because it was hot by this time. Mrs Carter believes it was around 10.30 am. Mr and Mrs Carter waited in the carpark and spoke to other walkers to try and prevent them walking up the trail. They spoke to one other couple while they were there, who agreed not to walk any of the trails out of respect to Mr Green.223

208. In the meantime, Mr Kefford and the others had driven back to the Tourist Park.

They spoke to the Tourist Park staff and reported what they had found. They were told that police had just rung to advise they had received information there might be a deceased person at the bottom of the mountain. It would seem this information had come from the call made by Mrs Carter to emergency services. Mr Kefford rang and spoke to police and told them the information they knew. Mr Kefford told police about the Prado in the carpark and also looked at the visitor’s book and noted the entry for Brian and Thelma Green. He immediately thought the worst and assumed that Thelma Green must also be missing somewhere.224

209. BSS Jackamarra had been at a course in Geraldton when Mrs Pollard’s death had been discovered, and she was called back to Burringurrah Community to assist with the investigation into Mrs Pollard’s death.225 BSS Jackamarra was at home when she received a call at 7.30 am on 16 September 2020 from the Geraldton Police Station to advise that the body of a male person had been located at Mount Augustus. She went to the Burringurrah MFPF and spoke to Sgt David Tapscott, who was relieving at Burringurrah Community. He had also been advised of the death. The officers made further enquiries and established that Brian and Thelma Green had signed the visitor book on 15 September 2020 indicating their intention to climb the summit and Mrs Green’s information was found on a backpack with the deceased man. Enquiries had also established that the unit where Mr and Mrs Green had been staying was empty and their car was located at the Flintstones carpark. All of this information indicated the deceased person was Mr Green.226

210. Sgt Tapscott and BSS Jackamarra left Burringurrah Community and drove to the Flintstones carpark, arriving at about 9.30 am. They saw the Greens’ car was parked in the carpark. The police met Mr and Mrs Carter in the carpark, who explained that they were the people who had reported the discovery of the body but the call had dropped out due to a poor signal. Mrs Carter then left to return to the Tourist Park and Mr Carter remained with the police to try and assist.227 Sgt Tapscott went to call the WA Police Emergency Operations Unit and BSS Jackamarra remained with Mr Carter. While they were waiting in the carpark, Sonia Davies and her son-in-law Luke Davis arrived in the carpark.228 223 Exhibit 2, Tab 17.

224 Exhibit 2, Tab 16.

225 T 195.

226 Exhibit 2, Tab 20.

227 Exhibit 2, Tab 19.

228 Exhibit 2, Tab 21.

[2022] WACOR 29

211. Ms Davies is the mother of Sheena Davies, the nurse who had assisted Mr Pollard, and Mr Davis is Sheena’s partner. Both Ms Davies and Mr Davis had helped with Mr Pollard’s rescue the day before. Their family had packed up and were ready to leave the Tourist Park that day when they became aware another man had died on the trail and his wife was missing. Ms Davies indicated in her statement she “didn’t see any action happening”229 and she was aware from the night before that it had taken the police over ten hours arrive, so she decided to go to the Flintstone carpark and look for the missing woman. Mr Davis offered to come with her and they left Sheena at the Tourist Park with the children.230

212. Ms Davies and Mr Davis introduced themselves and explained they had been involved in the search and rescue the day before and were there to offer their help again. BSS Jackamarra then made use of the three volunteers to begin searching the carpark and nearby area for any sign of Mrs Green, as she had realised from what the Carters had told her that it was likely Mrs Green was a missing person.231

213. Inspector David Hooper, who was stationed at the Mid-West-Gascoyne District Office, was advised at about 10.00 am on 16 September 2020 that Mr Green had been located deceased on Mount Augustus and his wife was unaccounted for.232 Inspector Hooper formed an Incident Management Team (IMT) at the Geraldton Police Complex and confirmed that officers from the Burringurrah MFPF had already departed their station to attend the scene. Inspector Hooper believed at that stage it would be a land search and rescue for Mrs Green and recovery for Mr Green.

BSS Jackamarra was appointed the Police Forward Commander as she was on the scene.233

214. Sgt Tapscott returned and it was arranged that he would walk to where Mr Green’s body had been located, with assistance from Mr Carter, Ms Davies and Mr Davis, while also searching the borders of the trail for any sign of Mrs Green. BSS Jackamarra remained in the carpark and shortly after, she was joined by Burringurrah Indigenous Rangers. BSS Jackamarra indicated she had already consulted with Mr Snowball, who she also knows as Junior, and another traditional owner, Mr Raymond Lockyer, to gain any assistance from their local knowledge. The rangers offered to search the lower level area adjacent to the carpark, and BSS Jackamarra accepted their offer. The rangers set off to search and returned a short time later with nothing to report. While waiting for Sgt Tapscott to return, BSS Jackamarra took a statement from Mrs Carter.234

215. Due to communications issues in Mount Augustus, Inspector Hooper had difficulty contacting BSS Jackamarra, who was located at the base of the summit trail. His attempts to contact her by mobile phone, satellite phone, CODAN radio and local police radio were all unsuccessful. Inspector Hooper was aware that communications in the area are extremely difficult. He eventually consulted Inspector Cox and it was decided that a senior officer would need to attend Mount Augustus to take carriage of the search and establish appropriate command and control in the absence of reliable 229 Exhibit 2, Tab 21.

230 Exhibit 2, Tab 21.

231 Exhibit 2, Tab 19 and Tab 21.

232 Exhibit 2, Tab 18.

233 Exhibit 2, Tab 18.

234 T 196; Exhibit 2, Tab 19.

[2022] WACOR 29 communications back to the IMT. Inspector Cox was subsequently appointed the Police Forward Commander to undertake this role and Police Airwing were requested to collect him and another officer and take them to Mount Augustus.

Inspector Hooper then went about the task of arranging for additional resources to attend Mount Augustus from Meekatharra Police, Yalgoo Police and Carnarvon Police, as well as requesting SES assistance.235

216. Sgt Tapscott walked for about 500 metres then activated his body worn camera so that he could record what he observed. After walking for approximately one kilometre, he noted the trail changed from a generally flatter west-to-east walk to a steeper northwest oriented walk, moving up the side of Mount Augustus. The trail became narrower at this point, only single width for walkers, and the land raised steeply with an uneven rocky surface, which made it a much harder, more physically demanding walk. At 11.25 am Sgt Tapscott arrived at Mr Green’s body, which was lying on his back on a rock ledge directly in the middle of the trail. He was described at the inquest as being located about halfway up the summit trail.236 It looked to Sgt Tapscott like Mr Green had sat on the ledge and then laid back on the track. He had a cream panama type hat covering his face, which Sgt Tapscott removed so that he could take some forensic photographs. There was no evidence of any major trauma on his head or body and no evidence of animal predation, but there was evidence of environmental exposure.237

217. Sgt Tapscott checked the pockets of the shorts Mr Green was wearing and found his wallet containing his identification. In the backpack Mr Green was carrying, Sgt Tapscott found the keys to the Toyota in the carpark, 3 x empty 600 ml water bottles, an uneaten apple and various other uneaten food items. The weather was very hot at this time, and with the radiant heat coming from the rocks combined with the air temperature, Sgt Tapscott estimated the conditions felt like 42 – 44 degrees Celsius.

The surrounding area offered very little shade as the trees were sparsely foliated.238

218. Sgt Tapscott asked the rest of the group to keep walking up to the summit, and then to return by the Gully Trail, in order to look for Mrs Green, while he made a number of phone calls via the Satellite Phone to the WA Police Emergency Operations Unit and Geraldton District Office.239

219. At about 10.50 am, Inspector Hooper received a satellite phone call from Sgt Tapscott, who was at the scene. Sgt Tapscott advised that he had located the body of Mr Green on the summit trail, approximately a 55 minute walk up the trail from the Flintstone carpark. It was said to be about halfway up the trail, almost midway between the carpark and the summit.240 Sgt Tapscott advised recovery of the body would be difficult due to the terrain and conditions and recommended at least eight officers would be needed to effect the walk out. He also advised that Mr Green had the car keys with him. This information suggested that Mrs Green might be further up towards the summit, as the police felt it was likely he was heading to the car to get help after something had happened to Mrs Green. A priority search area for Mrs 235 Exhibit 1, Tab 12.

236 T 19.

237 Exhibit 2, Tab 20.

238 Exhibit 2, Tab 20.

239 Exhibit 2, Tab 20.

240 T 19; Exhibit 4A.

[2022] WACOR 29 Green was then identified as the summit trail between the location of Mr Green’s body and the summit.241

220. Sgt Tapscott started to descend on the trail towards the carpark at about midday. He took with him the backpack that Mr Green was carrying. As he started to walk, he saw Ms Davies, Mr Davis and Mr Carter descending on the summit trail, so he walked back up to meet them. Ms Davies told him that they had found the body of a deceased female while they were walking up the summit trail. Ms Davies indicated that it was very clear the lady had died sometime earlier.242

221. Ms Davies explained in her statement that they found Mrs Green after walking about 35 minutes further up the path. She was at the front and saw Mrs Green first, so she alerted the others. It was very apparent to them that she had died and they did not disturb her. Ms Davies hung some pink tape around the body in the hope that this might help the police to locate her with a drone.243 Evidence was given by Inspector Cox at the inquest that Mrs Green’s body was actually located only a short distance further up the trail from Mr Green’s body, although the difficulty of the trail obviously means it takes some time to walk the distance between them.244

222. Sgt Tapscott indicated in his statement that he made the “critical decision at the time that due to the weather conditions and insufficient water not to ascent the trail to where the female was located.” He was satisfied from the information provided that the female was deceased and he was fairly certain the person was Mrs Green. The group returned to the carpark and Sgt Tapscott used the keys from the backpack to open the Greens’ Toyota Prado. Sgt Tapscott did not locate any food or bottles of water in the car, only some beer.245

223. Sgt Tapscott returned to the carpark around 12.45 pm and advised BSS Jackamarra that they had found Mrs Green and she was deceased. At about 12.48 pm, Sgt Tapscott rang Inspector Hooper again and advised that Mrs Green had been found, deceased, about a further 25 minute walk up the summit trail from Mr Green’s body.

The plan was now to arrange the recovery of both bodies off the mountain. All the searchers returned to the carpark to rest as they were quite fatigued after the initial search.246

224. Inspector Hooper was required to make another request to DFES to use SES personnel, now that it was a recovery operation only, rather than a rescue. The request to use SES personnel and resources to recover Mr and Mrs Green was formally declined by DFES at 2.20 pm. This left the task solely to police.247

225. Inspector Cox was informed shortly after take-off from Geraldton that the body of Mrs Green had been located. Inspector Cox continued on to Mount Augustus to organise the recovery of Mr and Mrs Green’s bodies from the mountain. Inspector Cox arrived at Mount Augustus between 2.30 pm and 3.00 pm and was then briefed 241 Exhibit 2, Tab 18.

242 Exhibit 2, Tab 20.

243 Exhibit 2, Tab 21 and Tab 22.

244 T 19; Exhibit 4A.

245 Exhibit 2, Tab 20.

246 Exhibit 2, Tab 18 and Tab 19.

247 Exhibit 2, Tab 18.

[2022] WACOR 29 by Sgt Tapscott before being taken to Mr Green’s body. With them was a police drone operator, Senior Constable Cohen, who they hoped would be able to use the drone to locate Mrs Green’s body.248

226. BSS Jackamarra remained in the carpark to ensure no other users of the trail were allowed access and to provide instruction to other police officers arriving to go up and assist with recovering Mr Green’s body.249

227. Sgt Tapscott and Inspector Cox and the others reached Mr Green’s body at about 4.40 pm. From that location, S/Constable Cohen used the drone to search the area above, but he was unable to locate Mrs Green’s body. A critical decision was made that due to the terrain and the time of day, it was not safe to continue further up the trail to try to locate Mrs Green’s body, and they would have to focus on recovering Mr Green’s body at that time. The plan was to return the next day to recover Mrs Green’s body.250’

228. They lifted Mr Green’s body and found a black iPhone on the rock under his back.

The phone was switched off. At about 6.00 pm, seven police officers removed Mr Green’s body and carried it to the carpark. They arrived in the carpark at about 7.30 pm and then transferred his care to the funeral contractors who were waiting in the carpark.251

229. After Mr Green’s body had been transferred to the contractors, it was 8.00 pm and dark. Inspector Cox confirmed the earlier decision that the dangers of walking the mountain in darkness made it unsafe to retrieve Mrs Green’s body that night. It was arranged that the recovery operation would recommence at 5.00 am the next day.252

230. At 5.00 am on Thursday, 17 September 2020, a dozen police officers, including Inspector Cox and Sgt Tapscott, walked up the summit trail to retrieve Mrs Green’s body. At about 6.30 am they reached the location of Mrs Green’s body. Sgt Tapscott estimated it was a walk of about 31 minutes from where Mr Green’s body had been located. Sgt Tapscott had activated his body worn camera for this walk as well, and he also took a series of photographs of Mrs Green’s location. Like her husband, Mrs Green was fully clothed, including wearing a full mosquito net over her head. She was lying in the middle of the trail, a short distance down from a low ridge of rocks.

She showed significant signs of environmental exposure. On the trail above Mrs Green’s body was a towelling material bag containing one empty 600 ml water bottle.253

231. Mrs Green’s body was carried down the mountain by the police officers. Her body was returned to the carpark by approximately 8.30 am and transferred to the contractors.254 Sgt Tapscott then went to the Tourist Park and was given the key to Mr and Mrs Green’s room. He found several bags of clothing and other personal effects in the room. There was no medication or indications of recent medication use.

248 Exhibit 2, Tab 20.

249 Exhibit 2, Tab 19.

250 Exhibit 2, Tab 20.

251 Exhibit 2, Tab 20.

252 Exhibit 1, Tab 12; Exhibit 2, Tab 19.

253 Exhibit 2, Tab 20.

254 Exhibit 2, Tab 18 and Tab 20.

[2022] WACOR 29 Some bottles of water, food items and cans of beer were found in the fridge. The room had the appearance that the occupants had intended to return.255

232. Sheena Davies, the nurse who had provided help to Mr Pollard, was still at the Tourist Park the next day when the search for Mr and Mrs Green began. She did not assist in the search but did spend much of Wednesday, 16 September 2020, warning incoming visitors to the Tourist Park of what was happening on Mount Augustus, in terms of the recent deaths and search for a missing person. From talking to the arriving visitors, it was apparent to Sheena that they were not being informed by staff of the Tourist Park, or any rangers, of the incidents on Mount Augustus. Sheena and her family were supposed to leave the Tourist Park that day, but ended up leaving the following day due to all the events that were occurring at Mount Augustus.256

CAUSE AND MANNER OF DEATH – MR AND MRS GREEN

233. On 21 September 2020 Forensic Pathologist Dr White conducted a post mortem examination of Mr Green after his body had been transferred to Perth. The examination showed evidence of decompositional changes and features of exposure, similar to the other deaths. There were scattered soft tissue injuries to the limbs, probably due to loss of coordination or a fall, but there was no evident injuries of significance. Coronary artery disease was present, which would have affected Mr Green’s ability to cope with the heat in a similar way to Mr Buske and Mrs Pollard.

Fatty change in the liver and scarring of the kidneys was also present, which was consistent with Mr Green’s medical history of type II diabetes and his GP records of issues with renal function. The fact that Mr Green’s kidneys were not working perfectly, as a baseline, may have played a factor in his death. Toxicology analysis found only aspirin in Mr Green’s blood, and a low level of alcohol that was likely related to decomposition rather than alcohol consumption.257

234. Dr White was given information about the circumstances in which Mr Green’s body was found, which included the highest temperature recorded on 15 August 2020 was 34.6°C but that the temperature on Mount Augustus is normally at least 3.5°C higher than the temperature at the recording facility, meaning it was at least 40°C on that day. The information suggested Mr Green and his wife had only 4 x 600 ml water bottles (2.4 litres) between them for the walk, as well as a small amount of food. Dr Luckin’s report was also reviewed by Dr White as part of her consideration of the cause of death.258

235. Dr Luckin considered that Mr Green’s risk factors were:259

• The extreme temperatures that day, with evidence from Sgt Tapscott (who was present to recover Mrs Pollard’s body) that with the large amount of radiant heat from the rock, the conditions felt like 42 - 44°C;

• Inadequate fluid consumption (Mr Green’s 3 empty bottles had a total capacity of 1.8 litres; 255 Exhibit 2, Tab 20.

256 Exhibit 2, Tab 1.

257 T 81; Exhibit 2, Tab 23 and Tab 24.

258 T 82; Exhibit 2, Tab 23.

259 Exhibit 3, Tab 13.1, p. 17.

[2022] WACOR 29

• Insulin-dependent type 2 diabetes mellitus;

• Reduced kidney function;

• Significant coronary disease;

• Clothing which did not protect his arms and legs from the direct sun and reflected heat from the rocks, noting one witness was concerned when she saw Mr Green was not wearing a hat when she passed him.

236. Based upon all the information available, Dr White concluded it appeared that Mr Green died due to the effects or complications of environmental exposure at high temperatures during sustained and strenuous activity leading to severe dehydration, hyperthermia, renal failure, cardiovascular collapse and death. Dr White was able to identify that renal failure had occurred, as a result of dehydration and heat stroke, by testing the vitreous humour. Dr White expressed the opinion the cause of death was heat stroke (environmental exposure).260

237. It was explained at the inquest that the physical stress of the environment may also have been compounded by psychological stress, if Mr Green had been distressed about needing to go and get help for his wife, who was found higher up the walking trail.

238. Dr White also performed the post mortem examination of Mrs Green on the same day as that of Mr Green, and Dr White reached a similar conclusion as to the cause of death. Dr White found features of exposure and decompositional changes and a slightly fatty liver but no other evidence of significant pathology and no significant injuries. Biochemistry was indicative of acute renal failure, likely in association with dehydration, as it was for Mr Green. Mrs Green’s toxicology results also showed a small amount of alcohol which was likely related to decompositional changes. Her medical history included osteoporosis, which possibly matched some degenerative changes seen in the spine, but nothing that would relate to the death.261

239. Noting the history of the same environmental circumstances as Mr Green, Dr White expressed the opinion the cause of Mrs Green’s death was heat stroke (environmental exposure).262 Dr Luckin had identified similar risk factors for Mrs Green, although she did not have the same medical conditions as her husband.

240. Inspector Cox concluded in his report that it appeared Mrs Green came into difficulties and perished first on the mountain. It appears Mr Green had gone to get assistance for his wife and made his way down the mountain, probably at speed, and perished while attempting to reach help.263

241. Mr and Mrs Green’s daughter told police that her parents were reasonably experienced hikers, having completed walks in Australia and overseas. They had planned their visit to Mount Augustus extensively, including researching the optimal time to visit the area, and had apparently spoken to others who had completed the walk, to get an idea of what to expect.264 However, Ms Underwood, who also walked 260 T 83 – 84; Exhibit 2, Tab 23.

261 T 84 - 85; Exhibit 2, Tab 25 and Tab 26.

262 Exhibit 2, Tab 26.

263 Exhibit 1, Tab 1, p. 47.

264 Exhibit 3, Tab 13.1, p. 16.

[2022] WACOR 29 the summit trail that day, suggested that at the very least, the information did not reflect the minimum time required to hike to the summit in those conditions.

242. I find that both the death of Mr Green and the death of Mrs Green occurred by way of accident.

ANOTHER RECENT NEAR MISS

243. On Wednesday, 15 October 2020, only a month after the deaths of Mrs Pollard and Mr and Mrs Green, another person, a 74 year old female, went missing on Mount Augustus. The next day, Inspector Cox was appointed the Police Forward Commander for this search, and he again flew to Mount Augustus. He was accompanied by three Tactical Response Group trackers and a Remote Drone Pilot.

SES staff had earlier headed there from Geraldton, Shark Bay and Carnarvon to assist in the search. On arrival at Mount Augustus, Inspector Cox was informed the walker had gone missing from the Edney Trail. The TRG trackers were deployed to walk along the top of the Edney Trail Walk lookout, and at 1.10 pm they located the walker alive. She had been lost for 26 hours at that stage. The rescued walker was put on a stretcher and taken to the First Aid Post, where she was administered first aid. She was then conveyed to the Burringurrah Community Nursing Post for assessment.265

244. The lady who was rescued was Mrs Margaret Ansell. Mrs Ansell had travelled from Perth with her husband on a driving holiday up north, which included visiting Mount Augustus. They had arrived in Mount Augustus on Thursday, 15 October 2020, one month after the deaths of Mrs Pollard and Mr and Mrs Green. They had never visited Mount Augustus before and had researched their trip on the DBCA website and the Carnarvon Shire website before they left. Mrs Ansell recalled she found researching Mount Augustus difficult as she was not able to find an awful lot of information and she could not download detailed maps. Mrs Ansell had not become aware of the recent deaths at Mount Augustus while doing her research. However, the Ansell’s intention was not to climb Mount Augustus in any event, as they were not interested in any kind of climbing challenge. They wished instead to look for photographic opportunities on other, easier trails, as the couple are keen photographers and were interested in wildlife and general terrain. Therefore, Mrs Ansell didn’t think the information about the deaths of Mr Buske, Mrs Pollard and Mr and Mrs Green would have altered their plans.266

245. Mr and Mrs Ansell left the Tourist Park, where they had checked in the previous day, at about 9.00 am on Friday, 16 October 2020. The weather was fine and clear and warm. They drove to Loop Drive and stopped at Cattle Pool to take some photos then drove on to The Pound, where they also got out and took a short walk. They then returned to the car and drove on to Edney Spring-Ooramboo trail, which had picnic tables and tourist facilities in the carpark. They arrived at about 10.20 am and had coffee and a biscuit before starting to walk the trail. They were hoping to see the Aboriginal art that is a feature of the trail. Mrs Ansell recalled it was classed as a Class 3 trail and about 150 metres long. They had understood from research that it 265 Exhibit 1, Tab 12.

266 T 87 – 89, 92 - 93; Exhibit 2, Tab 32.

[2022] WACOR 29 was “a relatively easy sort of walk.”267 As it was such a short walk, she and her husband decided they did not need to carry water. Mrs Ansell had consumed two mugs of coffee and about 500 ml of water before they started.268

246. The first part of the walk was fairly easy, but as they approached the Aboriginal rock art, the trail became more difficult because it started to go over rocks. They found the rock art eventually and Mrs Ansell decided she wanted to continue walking to the Spring from there. Mrs Ansell’s husband, who had recently had a hip operation, decided to return to the carpark as he found the trail too difficult to navigate because of the rocks. They agreed to separate and meet back at the car. Mrs Ansell was 74 years of age at the time and considered herself to be fairly fit and nimble for her age, although she had suffered a mild stroke a few years before, so she thought she would “just nip along” to the next bit and then return. The weather was warm but not overly so, and Mrs Ansell felt comfortable that she could complete the walk to the Spring quickly. They parted ways at 11.40 am and Mrs Ansell told her husband laughingly that if she wasn’t back by midday, he should “send out a search party,” not expecting this would actually be required.269

247. After leaving her husband, Mrs Ansell noticed the terrain changed and became more difficult, but she still reached the Spring after no more than five minutes of walking.

Because of the year, the Spring was dry. Mrs Ansell spent two or three minutes at the Spring taking photographs then decided to return to the carpark. However, when she turned around, Mrs Ansell could not see the trail marker directing her to the return route to the carpark. Mrs Ansell described the rock as very smooth and highly reflective, and the markers were small white ones on the ground, which made them hard to see in the tremendous glare. She eventually found the first marker, but was unable to see a second marker, despite walking in ever increasing circles from the first marker.270

248. Mrs Ansell was worried about her husband coming to look for her if she took too long, so she decided at that stage the safest course would be to follow the watercourse from the Spring, since she could not find the path. She assumed the watercourse would lead her back to the carpark as she had seen a small river by the carpark. Mrs Ansell followed the watercourse for 35 to 40 minutes without finding the carpark. It was a hard walk across sharp rocks and she wasn’t making much progress. Mrs Ansell decided to try and get some height to see if she could see the carpark from the elevated position. She walked up higher to some trees but could not find the carpark or any sign of it. Mrs Ansell became tired and rested in whatever shade she could find on numerous occasions, trying to keep cool and not to panic.

She tried calling out for help, as she was aware her husband would have gone to get help by this stage, but no one responded. It eventually became dark and Mrs Ansell decided she would need to seek shelter for the night. She took shelter at the base of a large tree. During the night she could see vehicle headlights in the distance and also noticed a fixed light, which she decided she would use as a marker to walk towards in the morning.271

267 T 88 - 90.

268 Exhibit 2, Tab 32.

269 T 90; Exhibit 2, Tab 32.

270 T 90; Exhibit 2, Tab 32.

271 T 90 – 91, 93; Exhibit 2, Tab 32.

[2022] WACOR 29

249. At about 5.00 am the next morning, being Saturday, 17 October 2020, Mrs Ansell woke up and began to walk in the direction where she had seen the fixed light. She walked until about midday, following a gully/stream bed until she reached the face of a cliff, which appeared to have some abandoned steps and old path. She climbed up the steps and found a marked path, where she then sat under a tree. Whilst sitting under the tree, Mrs Ansell was located by Mr Snowball and other searchers. She was taken on a stretcher to the carpark and was assessed by a nurse who determined she was suffering from dehydration. Mrs Ansell was taken to the Burringurrah Community Nursing Post for treatment and then discharged later that day. After resting for a day at the Tourist Park, Mrs Ansell presented to the Carnarvon Hospital Emergency Department to be medically assessed.272

250. After reflecting on these events, Mrs Ansell concluded she got lost because the signage for the return journey on the Spring trail was inadequate.273 Mrs Ansell said at the inquest her recommendation to others is that they should always take water when bush walking, even if only going for a short walk, have an agreed plan as to what to do if things go wrong, and to always do some research in advance, in particular taking the time to talk to the locals in the area before heading out.274

OTHER EARLIER DEATHS AT MOUNT AUGUSTUS

251. A Japanese national, Mr KT, died at Mount Augustus in late December 2004. Mr KT, who was 55 years of age, flew to Perth from Japan in late December 2004, apparently for the sole purpose of climbing Mount Augustus. He flew from Perth to Carnarvon and drove straight to Mount Augustus. Of note, he would have come from the cold of winter in Japan to the full heat of an Australian summer in the mid-west.

He drove to the summit trail at about 7.45 am on 25 December 2004. Mr KT was only noticed missing the next day, being Boxing Day 2004, from his accommodation. His car was located at the Flintstone carpark and police were notified. A search was commenced at first light on 27 December 2004 and his body was found at about 2.45 pm in bush between the Summit and Gully Trail, approximately 1.5 kilometres from the carpark. It was estimated the temperature would have been around 40 degrees Celsius on the day Mr KT died. His cause of death was given as consistent with environmental exposure and inanition.275

252. Mr AH and his father were travelling around Western Australia on holiday from Victoria in February 2015 when they visited Mount Augustus. Mr AH left the Mount Augustus Tourist Park at 7.00 am on 28 February 2016 and drove to the summit trail.

When he failed to return by 6.00 pm, his father raised the alarm. Mr Don Hammarquist was at the Tourist Park at the time. He drove to the Flintstone carpark and found Mr AH lying next to his vehicle, deceased. It appears he had attempted to get into the driver’s side of his car but had fallen on the ground, where he died. Mr Hyland was 52 years of age at the time of his death. His cause of death was determined to be coronary artery atherosclerosis, and his death was due to a natural 272 T 91; Exhibit 2, Tab 32.

273 Exhibit 2, Tab 32.

274 T 93 - 94.

275 Exhibit 1, Tab 1, pp. 47 – 48.

[2022] WACOR 29 cause, but I note it is in the context of what is detailed below by Dr Luckin about the effect of heat exposure on the cardiovascular system.276

253. Mrs ER-K and her husband arrived in Western Australia from Switzerland on 27 October 2016. After travelling for a short period of time through the State, they arrived at the Mount Augustus Tourist Park on 5 November 2016. At around 8.00 am on 6 November 2016, they drove their car to the Edney’s walking trail. It was estimated to reach a high of about 40 degrees Celsius at Mount Augustus that day.

The couple both walked approximately 3 kilometres to the pinnacle lookout, where they stopped to take some photographs. Mrs ER-K began to suffer breathing difficulties during the walk. She had previously suffered from cardiopulmonary health issues. Mrs ER-K eventually collapsed approximately 50 metres short of the carpark. Her husband attempted to contact emergency services utilising a GPS beacon supplied by the hire car company. He then left his wife in the care of two other hikers and drove back to the Tourist Park to seek help. Emergency services were notified and police and a nurse from Burringurrah Community came to help.

Sadly, Mrs ER-K could not be revived. Her cause of death was determined to be consistent with acute cardiac failure secondary to environmental hyperthermia (heat stroke) in a woman with known cardiovascular disease.277

THE WAJARRI YAMATJI CORPORATION

254. There has been recent progress made in formally recognising the rights of the First Nations people, the Wajarri People, in the area that surrounds, and includes, Mount Augustus. Mr Dwayne Mallard is the Chairperson of the Wajarri Yamatji Corporation, which is a prescribed body corporate that manages the native title rights and interests of the Wajarri Yamatji people’s determined area. Mr Mallard explained the area is very large, being a little bit bigger than Tasmania, and includes Burringurrah Community and the Mount Augustus national park and pastoral area.

The Corporation is a relatively new entity. Following a conditional determination on country on 19 October 2017, the prescribed body corporate was only set up and claim determined fully in July 2021. Mr Mallard chaired the native title claim for five years and became the chairperson of the prescribed body corporate in November last year.

255. The Wajarri Yamatji determined claim is made up of four clan or land groups, one of those being the Burringurrah area, with the other three land groups being Nunaru (on the Meekatharra side), Meenangu (in the heart of the Murchison) and then the Burrow Plains. With those four land groups come cultural decision-making bodies, who have only recently been formed. Mr Mallard explained it is quite a lengthy and involved process to ensure that there is free, prior and informed consent around how to create cultural governance and decision-makers with knowledge holders and authority, so it required a lot of consultation and information sharing to get to this stage.278 As a result, Mr Mallard explained at the inquest that they have not yet started the process of negotiating with other entities as at this stage.279 276 Exhibit 1, Tab 1, p. 48.

277 Exhibit 1, Tab 1, pp. 48 – 49.

278 T 229.

279 T 228 – 229.

[2022] WACOR 29

256. Mr Mallard is not from the Burringurrah clan group. His cultural authority relates to a different clan group in the area. Therefore, Mr Mallard, sought permission from Mr Snowball, who is the most senior elder within the community of Burringurrah, and Mr Raymond Lockyer, another elder with cultural authority to make decisions in relation to Burringurrah, before speaking at the inquest about their aspirations for the future. As noted at the start of the inquest, Mr Snowball also made time to speak to me and the various counsel prior to the full inquest commencing, to give his own personal views, but he was not available to give evidence at the inquest.280

257. Prior to discussing the individual issues and recommendations, Mr Mallard paid his respects to the deceased and their families and acknowledged their trauma and sorry business and gave condolences from the Wajarri community. Mr Mallard expressed very eloquently the importance of these issues to the Wajarri people, stating that,281 It hurts us all when something happens on our country and our land. We’re born into the responsibility and obligation to preserve and protect and restore dignity of our land and our culture and our people, and that includes our visitors, and we want to ensure that their access and safety is paramount to their experience on our country and we would like to play a role in that, to ensure the safety of our visitors.

258. Mr Mallard indicated that from speaking to Mr Snowball, he is aware that these deaths have weighed heavily on him personally, particularly as he was a first responder when they were reported missing.282

259. Mr Mallard also explained that the members of their community want visitors to understand and learn the essence of their culture and appreciate that the area is not a tourist attraction, it is a significant sacred site. They want visitors to come from all around the world to appreciate not only the ‘largest rock in the world’, but also to share the sacredness and reverence of the area with the traditional custodians who have been its guardians for thousands of years.

260. Mr Mallard gave evidence that his contact with DBCA in his role as the chairperson has been intermittent but it has been progressive and very respectful. He indicated that the traditional landowners approached DBCA three or four years ago around establishing a ranger program in the area. Mr Mallard then sat down with Nigel Sercombe, the regional manager for DBCA for the Murchison and Gascoyne, last year to talk about how the ranger program was, and wasn’t, working in the region.

Mr Mallard indicated the rangers needed more resourcing and wanted to have a more continued presence up at the Mount and have more say in how it was managed. Mr Mallard gave evidence his request was met with genuine respect by DBCA. To that end, in January 2021 they had a meeting in Gascoyne Junction with a number of people from the corporation and DBCA staff “and genuinely leaned into what it might look like in terms of how we managed the park itself.”283 Following that meeting, DBCA placed a senior ranger permanently during the peak season at Burringurrah Community and took on four full-time trainee rangers from the

280 T 230.

281 T 230.

282 T 231.

283 T 232.

[2022] WACOR 29 Burringurrah Community. The importance of this for the community is demonstrated by the fact that this was the first time since 2006 that anyone from the community has been employed full-time to do work on country. Mr Mallard explained that this creates economy for the community which is important, but it also “connects us back again to the essence of who we are around caring and protecting and preserving country, including keeping people safe.”284

261. Mr Snowball is the boss of the four other rangers and their job includes making sure everything is okay around Mount Augustus, tourists are keeping to the tracks and not going into sacred areas and caring for their land, including the flora and fauna species, and their culturally significant sites. They also walk the Summit Trail regularly in the cooler months. The Indigenous rangers, and in particular Mr Snowball, have views about what changes might be made to improve the safety of the Summit Trail walk.285 The aspirations of the traditional custodians, culturally and socially, is therefore to have a greater involvement in what changes are made at Mount Augustus. Mr Mallard described that involvement as taking place in crosssectional collaboration with DBCA, the police, DFES, the Shire and WACHS, working together to co-design a response that is appropriate for the area and has got cultural content and is responsive to the primary need of “how do we keep people safe when accessing the park.”286

262. Mr Mallard suggested that it might be facilitated by a park permit system, such as in place in some other WA national parks. Mr Mallard explained that even he, as a Wajarri person but not from the Burringurrah area, seeks permission before he ascends to the summit at Mount Augustus, and it would be appropriate for all people to seek that permission from the traditional landowners. Further, it would create economy to support the rangers and the rest of the local community to maintain the site. Mr Mallard indicated that ultimately, one suggestion to have only ranger guided walks on the Summit Trail, and possibly others trails in the park. He noted that he has been at the summit and heard the conversations of the other people there centring only around what caravan they are towing and whether they had phone reception and where they were planning to go next. Mr Mallard observed that these people had missed the opportunity to appreciate the significance of the story and sense of the place, which could be facilitated by ranger-led walks. Unlike at Uluru, where it is considered culturally insensitive to climb, the Wajarri people have never said they do not wish people to climb Mount Augustus. However, they do want people to appreciate the sacredness of the area and to also stay safe while doing so.287

263. Mr Mallard also suggested that ranger-guided walks would be beneficial from a safety perspective and Mr Snowball also expressed this view.288 Mr Mallard gave evidence he has been the youngest person at the summit by at least 20 years, and noted the walk was tough on him, so he was concerned for the safety of the other walkers. With a ranger-guided walk, the capability of people to undertake the walk could be initially assessed by the rangers, the welfare of the walkers on the trail could be monitored and the rangers could have PLB’s and other equipment to raise the alarm in the event of an emergency. This would eliminate much of the risk of

284 T 232.

285 Exhibit 3, Tab 10.

286 T 232.

287 T 233.

288 Exhibit 3, Tab 10 [34].

[2022] WACOR 29 people getting into distress and then not being able to call for help. Mr Mallard emphasised that it is possible to do the walk safely and make it an enjoyable experience, but it requires doing it at the right time of year and at the right time of day, as well as the knowledge and sensibility of what water and other provisions are necessary for the journey. The rangers have this requisite knowledge and they can play an important death prevention role at the Mount Augustus National Park.289 Mr Snowball had also indicated that the rangers can help track through traditional ways, so he would like to be informed straight away when someone goes missing.290

264. Mr Mallard noted that all of these are simply suggestions at this stage, and it needs to be a collective approach with government playing a significant role, but with the community at the forefront of the response as it involves the management of their traditional lands. In that sense, Mr Mallard suggested that the commercial implications for the Tourist Park in whatever decisions are made must, by necessity, play a lesser role in the decision-making process.291

265. Mr Mallard indicated that following discussions with Mr Snowball and Mr Lockyer, he could advise they would support a closure of the Summit Trail for at least the prime summer months of December and January, because the temperatures are extreme and the summer winds also make the conditions dangerous at the top. Mr Mallard suggested that from the traditional custodians’ perspective, the best solution would be a mix of closure in the extremely hot season and then guided tours in the peak tourist season. This would allow the traditional custodians to do maintenance and collaborate with infrastructure construction works in the park, when the walks were closed, so they would still have work all year round. While the details have not been worked out, Mr Mallard indicated the traditional landholders were supportive of improvements such as toilets and shade structures in the area, so long as people such as Mr Snowball and Mr Lockyer are consulted and the local community is included in a meaningful way by providing employment, training and supply chain opportunities.292

266. Mr Mallard noted that throughout the lockdowns brought on by COVID, the Burringurrah community has not had food, hygiene and fuel security, with the closest fuel and snack food at the Tourist Park, and the nearest town for proper food, fuel and other supplies generally being Carnarvon, a 480 km drive away. They want to take advantage of the economic opportunities presented by people wishing to travel within Western Australia to benefit the local landholders and created a stable economy for them, rather than have the traditional custodians and knowledge holders left behind under the guise of tourism. As Mr Mallard put it, the time is right now to consider how we preserve and protect and restore the dignity of that area for all to benefit, noting the lives that have been lost and the need to move forward in a more considered way.293

267. Similarly, members of the Wajarri Yamatji Corporation have been in talks with the WA Police and DFES about ways to improve telecommunications in the area, which the traditional custodians also support, and ways to involve the rangers and other

289 T 233 - 234.

290 Exhibit 3, Tab 10 [38] – [39].

291 T 234.

292 T 237 – 238.

293 T 236 - 237.

[2022] WACOR 29 members of the Burringurrah Community in emergency response situations. Mr Mallard noted that Mr Snowball is often involved as a first responder, in an unfunded role, and there is capacity to formalise that role and provide training and properly equipped emergency vehicles at the community.

268. Mr Mallard emphasised that the Burringurrah Community is ready and willing and able, and wants to be part of an intrinsically enmeshed solution that preserves lives and values the sacredness of the area. They very much want to be part of that solution as these deaths weigh heavily on the traditional custodians. They are also very supportive, in principle, of some sort of permanent memorial being placed in memory of the lives lost, and as a warning to others, although there would obviously need to be consultation with Mr Snowball and others as to what that memorial looks like and where it is positioned.294

INSPECTOR COX’S REPORT

269. Inspector Cox was the Inspector in charge of the WA Police Mid-West Gascoyne District Office at the relevant times of these deaths. He was personally involved in all of these matters and prepared an extremely comprehensive Coroner’s Report in relation to the deaths of Mr Buske, Mrs Pollard and Mr and Mrs Green. I am indebted to Inspector Cox for the thoroughness of his investigation and his thoughtful and considered response to these deaths. It is obvious that he has given a great deal of time and energy to thinking about how an inquest might achieve positive change in the Mount Augustus region, and he consulted widely with relevant organisations and agencies in order to provide some suggested recommendations for my consideration that might help prevent further similar deaths. I freely admit that I have used Inspector Cox’s report as a guide to this inquest and my findings, and I express my gratitude to him for helping to make this difficult task a little easier. I hope that the holding of this inquest and the changes that have already occurred, as well as any recommendations that flow from it, repays Inspector Cox for his efforts by resulting in changes that save lives and make the job of the police in the MidWest Gascoyne District a little easier in their role as the emergency responder at Mount Augustus.

270. I note this inquest has covered the preventable deaths of four people in a very short space of time. As detailed above, in fact a total of seven people have died on Mount Augustus since 2004. Further, it is very plain to see that there have been a number of other near misses, such as Mrs Ansell and Mr Pollard.

271. All of the deaths occurred while the people were on their way back from the summit.

Some, like Mr Buske and Mrs Pollard, actually made it almost to the carpark.295 Other people have been known to actually make it to the carpark before they have died. Inspector Cox gave evidence that in Mr Buske’s case, it appeared that he was dehydrated and delirious and has walked off the trail and gone the path of least resistance down, which was a dry riverbed. The others have died in various locations on the trail, but all while heading back down. Other than that, there is little pattern to where they died.296

294 T 238 - 239.

295 T 20.

296 T 20.

[2022] WACOR 29

272. In preparing his report, Inspector Cox noted that there were a number of causal factors similar in all of the deaths (and indeed, the near misses), namely:297

• The extreme heat on Mount Augustus at the time of their deaths. All of the people have died in the hotter months of the year, from September to March, when temperatures on the mountain can reach past 40 degrees Celsius.

• The mistaken belief that all hikers can safely walk the summit trail in the extreme heat.

• A lack of communications on the mountain for any of the hikers to raise the alarm that they needed assistance.

• The failure of the hikers to carry a personal locating beacon.

• The absence of emergency response resources in the area.

273. In addition to the above factors, I note that in all of the cases, when these people went missing they had left their cars in the Flintstone carpark, which was an obvious early indicator that something may have happened to them, if anyone had been checking and noticed that their cars were still there in the evening. However, not only are there no emergency response resources in the area, but there is no one who has the responsibility of monitoring who goes up and down the summit.

274. Inspector Cox provided his report to the Coroners Court on 23 November 2020, a year to the day prior from when the inquest commenced. At the conclusion of his report, Inspector Cox detailed 15 proposed recommendations in total, that were intended to lower the risk of subsequent deaths at Mount Augustus occurring, and to improve the emergency response.298 The recommendations were formulated after consultation with many of the relevant people who live and work in the area, as well as the agencies involved in managing the site and providing the emergency response.299

275. Inspector Cox did express some frustration with DBCA, both in his report and during his evidence at the inquest, as he believes “the DBCA should take the lead role in all this because it’s their national park.”300 Inspector Cox felt that his requests for information from DBCA, prior to finalising his report, were frustrated at times by a lack of information being provided by DBCA staff. He indicated at the inquest that, from a personal perspective, “it would have been nice if more input from the DBCA [cam] in a more timely fashion to assist us.”301 Evidence was given by DBCA staff that there may have been some confusion between the police and DBCA staff as to who was the appropriate person to provide the information that Inspector Cox sought. I address this further below.

276. In the year that passed between receipt of the report and the inquest there has been further consideration by the various organisations and agencies involved, prompted in part no doubt by the upcoming inquest and an understanding of the content of Inspector Cox’s report. As a result, by the time of the inquest, there was additional 297 Exhibit 1, Tab 1, pp. 7 - 9.

298 Exhibit 1, Tab 1, pp. 7 - 9.

299 T 41; Exhibit 1, Tab 1, pp. 52 – 64.

300 T 42.

301 T 61.

[2022] WACOR 29 information available as to changes that had been already implemented, and others that are proposed. One important change is in relation to the plans for significant improvements to mobile coverage on the summit, which I will cover below.

277. In addition, since the inquest was held, I have been informed that some more changes have been progressed, in particular in relation to signage erected by the DBCA, who manage the site. I will address those changes as part of my consideration of the proposed recommendations below.

278. I am obviously not bound by the proposed recommendations in framing any recommendations I choose to make, but they provide a convenient framework in which to consider what more, if anything, should be done. For the sake of simplicity, I will address each proposed recommendation in turn, and then indicate whether or not, after considering all of the evidence, I make a recommendation of that kind.

DBCA

279. Mr Stephen Nicholson is the DBCA District Manager for the Gascoyne District within the Mid-West region and is based in the Shark Bay District Office. Mr Michael Phillips is the Visitor Risk Management Coordinator for the Parks and Wildlife Service within the DBCA and is based in Perth, where he provides training and guidance to DBCA staff throughout Western Australia as well as being involved in corporate reporting and governance of the agency. Mr Nicholson provided a statement to police in November 2020 and Mr Phillips provided to the Court a statement and comprehensive report to the Court in October 2021, which included responses to some questions raised by Counsel Assisting. Mr Nicholson and Mr Phillips both also gave evidence at the inquest.

280. Although I have noted above that Inspector Cox expressed some frustration in relation to his early dealings with DBCA in preparing for this matter, I accept that there may have been some misunderstanding between the police and DBCA as to what information could be provided by DBCA and by whom at an early stage, and what information would be provided closer in time to the inquest. It is an example of how the channels for communication between agencies can always be improved. I can indicate that by the time of the inquest I had received comprehensive information from DBCA in relation to all of the relevant issues, including responses to Inspector Cox’s proposed recommendations.

281. Before going to the recommendations, it is perhaps helpful to note some of the salient information provided by Mr Nicholson and Mr Phillips as to the situation as it stood with DBCA in relation to Mount Augustus at the time of these deaths.

282. Mr Phillips explained, as a starting point, that from the DBCA perspective (which is the State Government perspective), national parks are conservation estate and their “primary purpose is the protection of conservation and natural and cultural values.”302 The attractions side of the Department includes places such as Perth Zoo, Kings Park and Rottnest Island, but the Summit Walk at Mount Augustus would 303not fall within that category, although recreation at a national park is a valid use of

302 T 359.

303 T 359.

[2022] WACOR 29 those area. Mr Phillips acknowledged that there are some risk factors for recreation at Mount Augustus, due to the heat and rocks that are part of the natural environment. He indicated that it is “about balancing the risks of those things with protection of the cultural and conservation values” while also allowing access as best they can to a wide range of different uses.

283. In terms of the risk assessment process that is actually undertaken, Mr Phillips explained it is a four-step process based on the Australian standards for risk assessments, in which the hazards are identified and ranked based on risk scores. The best treatments for them are then determined, with the aim to eliminate the risk if possible, and the treatments are put in place, then monitored and reviewed over time to see if they are effective and to identify if any new hazards have emerged. Mr Phillips trains and advises other DBCA staff on how to conduct this process, rather than generally attending the regions and doing the risk assessments himself. Mr Phillips indicated the process is also informed by feedback from visitors and obviously if there are fatalities or serious incidents, that may prompt a discussion and review.304

284. In terms of walking trails in particular, Mr Phillips explained that trail management is based on the Australian standards for walking trail classifications. That standard is used to determine the class of the trail and, from that, what are the standard sets of requirements for signage, trail markings and the like. Interestingly, on the higher class 5, which applied to the Gully Trail at the time and now also the Summit Trail, the standard indicates there should be almost no trail markings. However, Mr Phillips gave evidence that DBCA has approached the Mount Augustus Summit and Gully Trails differently after gaining a better understanding of visitor profile and demographics, and DBCA has marked the trails more frequently than they normally would or is recommended by the standards. Mr Phillips indicated that there is a Recreation and Trails Unit at DBCA who ultimately decide on the trail markings that are to be put in place.305

285. As noted above, Mr Nicholson is based in the DBCA Shark Bay District office in Denham and in November 2020 he had approximately 32 staff members in his team, including six rangers and two ranger assistants. After the DBCA Carnarvon office closed in December 2018, the Shark Bay office became the closest office to Mount Augustus National Park, even though it is between an eight to nine hour drive from the Shark Bay office to Mount Augustus. Mr Nicholson indicated that the “type of facilities and the level of visitation at Mount Augustus National Park, as with many remote national parks, does not warrant a permanent onsite presence by DBCA.”306 Instead, DBCA staff would do visitor risk assessments at Mount Augustus annually and also visit the park once every four to six weeks during the high season from April to October.307

286. On 11 November 2019, two days after Mr Buske went missing, DBCA say they were notified of Mr Buske’s death and Mr Nicholson travelled to Mount Augustus to try to

304 T 357 - 363.

305 T 364.

306 Exhibit 3, Tab 3 [34].

307 Exhibit 3, Tab 3 and Tab 16, p. 33.

[2022] WACOR 29 assist with the emergency response. Mr Buske was found before he arrived, but he assisted with some aspects of the investigation into his death.308

287. It does not appear a review was conducted by DBCA immediately after Mr Buske’s death, but in July 2020, Mr Phillips was in Denham delivering training with another colleague, experienced in visitor risk management, and they had a meeting with the local Shark Bay District DBCA staff to consider what steps might be taken to improve visitor information at the Tourist Park and the like. Some changes were suggested, including installing a new heat risk sign in the Flintstone-Beedoboondu carpark, bringing the heat risk information to the front panel of the information shelter and ensuring information is provided to visitors about heat stress, the amount of water required and the importance of starting the walk early.309 The changes had not been implemented before the deaths in September 2020.310

288. Mr Nicholson found out about Mrs Pollard’s death on the day her body was discovered from the local Shire’s CEO, Mr John McCleary. He was then notified the following day by police of the deaths of Mr and Mrs Green. He was not sure why the police did not notify DBCA of Mrs Pollard’s death and suggested it would be better if the notification was given as DBCA may be able to assist with local knowledge.

Mr Nicholson did not attend Mount Augustus at this time, but DBCA did offer support and assistance in whatever way it could.311 Mr Nicholson also recalled that the police contacted him after Mr and Mrs Green were discovered to ask if DBCA would close the park, which they did. Mr Nicholson understood the request was made in order to allow the police to complete their search and rescue efforts unhindered, rather than due to any elevated risk at the site.312

289. It does not seem that anyone had suggested closing it before then, following the discovery of Mrs Pollard’s death the day before. Mr Nicholson indicated that DBCA would not normally do so without a discussion with the police, and in this case he did not believe the police had made such a request. Mr Nicholson gave evidence that an incident like Mrs Pollard’s death would not normally prompt DBCA to consider closure on their own initiative in the circumstances that arose at this time. He agreed that if there had been some natural event such as an avalanche or flood or fire, it might prompt a different response from DBCA, but simply hot conditions didn’t suggest an increased risk to all visitors.313

290. A few days later, on 20 September 2020, the annual visitor risk management inspection was conducted by DBCA staff of the Summit Trail and Gully Trail.

Although it was not specifically prompted by the three deaths, Mr Phillips indicated having three deaths over two days in a Western Australian National Park was unprecedented, so the staff were expected to consider whether there was something unusual at Mount Augustus that had caused these events while conducting the annual assessment. I note that this assessment did not highlight any new or unusual hazards

308 T 332.

309 Exhibit 3, Tab 3, pp. 45 – 46.

310 T 375.

311 T 332 – 333.

312 T 333 313 T 334, 356, 377; Exhibit 3, Tab 3.

[2022] WACOR 29 and indicated that the assessors felt that the trail classification was still appropriate.

The trail was reopened after this assessment was completed on 20 September.314

291. However, DBCA did make some changes in other ways, committing to have a staff presence at Mount Augustus National Park following the incidents until the end of the school holiday period on 11 October 2020 and installing some quickly produced “Are you ready for this hike?” signage based on the designs in place in Kalbarri National Park.315

292. In May 2021, a larger review of Mount Augustus was conducted by DBCA staff, including the Recreation and Landscape Coordinator Unit staff and Mr Phillips, to assess the trails and facilities. One of the changes that arose as a result of that review, was the reclassification of the Summit Trail to a class 5, based on advice from the Recreation and Trail Unit leader and Recreation Unit leader, who walked the Summit Trail and the Gully Trail at that time in order to conduct a full assessment. 316

293. Mr Phillips acknowledged in his evidence that he thinks the interpretation of those standards and classifications is not really understood by most visitors to national parks and he doesn’t think they are described in language that an average member of the public would understand. Therefore, he accepted that there is space to communicate the information better to visitors, in the form of visual representations such as symbols and pictures, rather than just trying to explain it in text. This would also be of benefit to foreign visitors, an issue raised by Mrs Buske’s counsel during the inquest.317

294. Mr Phillips was involved in many of the improvements that have been implemented in Kalbarri National Park in recent years (in response to a number of heat-related incidents including one fatality), which have been spoken of with enthusiasm by many of the witnesses in this inquest. Mr Phillips explained that during 2018, one of the emerging risk issues identified by DBCA was the number of heat stress/stroke related issues that were occurring in Kalbarri National Park, as well as other northern areas of the State. The particular increase in these incidents in Kalbarri resulted in a review of heat-management strategies in Kalbarri, which then identified a series of primary and secondary management strategies that could be implemented. Mr Phillips agreed at the inquest that some of those options that have been trialled at Kalbarri may be suitable for Mount Augustus. I set them out in more detail, where relevant, below under the proposed recommendations, noting that the strategies are still in the implementation and review stage in Kalbarri.318

295. Mr Phillips gave evidence DBCA has not attempted to trial any of these new options at Mount Augustus yet, as the level of visitation at Mount Augustus is much less than Kalbarri, even when taking into account the recent increase, and one of the lowest of all their national parks (for example, as compared to the Leeuwin-Naturaliste National Park in the very popular south-west of the State). Mr Phillips advised that there has been an enormous increase in visitation to all of the DBCA National Parks and attractions, including an increase of 155% at the Stirling Range National Park 314 T 377 - 379; Exhibit 3, Tab 5, VRM1, 20 September 2020.

315 Exhibit 3, Tab 16, pp. 47 – 48.

316 T 364 – 365.

317 T 365 - 366.

318 Exhibit 3, Tab 16, pp. 26 – 32 and Attachment 17.

[2022] WACOR 29 that includes Bluff Knoll as a result of the State Government’s tourism campaigns coupled with COVID, and DBCA was given no additional resources to manage those increases. Mr Phillips noted that in some remote locations, such as Karijini, they are fortunate to have cooperation from local mine site staff in emergency situations, but Mount Augustus is even more remote and isolated, which presents its own particular challenges. However, with the unexpected boom of the State Government’s funding commitment, there is now an opportunity for DBCA to be involved in implementing some important safety improvements at Mount Augustus.319

PROPOSED RECOMMENDATIONS 1 – Close the Summit Walk Trails September to March

296. It is fair to say that the first recommendation, that the Summit Trail be closed from September to March each year, was the most controversial and debated recommendation at the inquest hearing. It was also the recommendation that Inspector Cox considered to be the linchpin for future death prevention. He gave evidence that he thinks “the only way to prevent deaths is to close the Summit Trail for a six month period.”320

297. Inspector Cox noted that all of the seven deaths in recent years at Mount Augustus have occurred within this time period, with three deaths in September, two in November, and one each in December and February.321 I note that following Mr KT’s death in December 2004, the Mount Augustus Senior Operations Officer for the Department of Conservation and Land Management (now DBCA) wrote in a letter to the WA Police that Mount Augustus National Park experienced a quite distinct tourist season, due primarily to the extreme temperatures of summer, “which discourage all but the most intrepid to visit the area.”322 When one considers the people who have died since then, it has to be concluded that if this was true before, it is no longer the case. Inspector Cox observed in October 2020 there were a high percentage of retired people at the Tourist Park,323 similar to the Greens and the Buskes, so the demographic is obviously changing.

298. Inspector Cox noted that currently, unless the DBCA close the walk (which is rare), the decision whether a person should walk to the summit rests solely on the individual, who makes the decision based upon their knowledge of their own capabilities, within the context of what they know about the challenges of the walk.

Unfortunately, what has been shown is that people underestimate the physical effort the walk requires and the conditions that they will face while doing so. This is particularly true during the so called ‘summer months’, which run officially from December to February, but when you consult the Bureau of Meteorology statistics, would suggest apply to Gascoyne from October to March. The mildest temperatures are recorded in the months from May to September, but as the experience of the

319 T 366 – 371.

320 T 43.

321 Exhibit 1, Tab 1, p. 66.

322 Exhibit 1, Tab 1, p. 67.

323 T 38.

[2022] WACOR 29 Pollards and the Greens demonstrates, there can be very high temperatures recorded on the summit trail in the shoulder months such as September.324

299. It is relevant to note that Mr Snowball, who is a traditional custodian of the land, born and bred in Burringurrah Community, and who works as the Indigenous Park Ranger at Mount Augustus, said he wouldn’t walk up to the summit himself in the summer time, because it is too hot then. Mr Snowball described this period as October to Christmas time.325 Weight must be given to Mr Snowball’s reluctance to walk up to the summit at the hottest times of the year, even though he is well acclimatised to the weather and knows the area intimately. He thinks people are “mad”326 to even attempt it at these times, as it’s just too hot.

300. When Mr Snowball does go up to the summit, in the so-called ‘cooler’ months, he usually leaves at around 5.00 or 6.00 am, before it is light, in order to try and avoid as much of the heat of the day as possible.327 Mr Snowball gave evidence that if he is at the base of the summit and sees people attempting to start the walk later in the morning, at 8.00 or 9.00 am, he will turn those people away and explain to them that they have left their start too late for it to be safe. Mr Snowball said that some people will get a bit grumpy with him at these times, but generally they abide by his suggestion.328 I give significant weight to Mr Snowball’s views about the appropriate timing of any walk to the summit, as he has done the climb many times himself and has also had to step in and help on the occasions when people have come into grief, so he knows how and when it goes wrong. Mr Snowball indicated that he supports closing the Summit Walk in the hotter months.329

301. Dr Luckin has not been to Mount Augustus, but based upon his personal experience in extreme conditions, and the information available to him about the Summit Walk, he expressed a similar position to Mr Snowball. Dr Luckin gave evidence he would not personally walk the trail in the summer, and if he were to walk it in the winter months, he would plan to leave at sunrise, which is usually around 5.30 am. This is because even in the so-called cooler months of the year, temperatures can still be well above 30°C with a high RH at an average of 68%. This kind of air temperature and humidity, when coupled with the intense radiant heat reflected off the rocks, makes it a challenging walk even at that time of year. Dr Luckin commented that “the reflected heat from the ground in that environment is absolutely incredible”330 and needs to be experienced to be believed, citing the accounts of the police officers who were involved in recovering the bodies of Mrs Pollard and Mr and Mrs Green.

Dr Luckin commented that it can actually feel hotter being exposed to the intense radiant heat from the ground than the radiant heat from the sun, which is why it is so important to protect the arms and legs to stop radiant heat absorption.331 324 T 36; http://www.bom.gov.au/climate/averages/tables/cw_006022.shtml; Climate statistics for Australian locations (bom.gov.au).

325 T 15 - 16.

326 T 35.

327 T 8 – 9.

328 T 15 - 16.

329 Exhibit 3, Tab 3 [35].

330 T 122.

331 T 122, 130.

[2022] WACOR 29

302. Based upon the information he had reviewed, Dr Luckin expressed the opinion that generally, he would think it was very unwise to attempt the walk where the forecast is for 36°C or greater.332 As to whether the Summit Trail should be closed entirely in the hottest months, Dr Luckin commented that from the point of view of a doctor who wishes to preserve life and avoid unnecessary death, he would say “yes, it should be closed.”333 However, Dr Luckin also believes realistically that this tactic is unlikely to succeed, as he believes many people will not obey the direction and will simply walk around any barriers, noting it is impractical to fence off the area entirely. Therefore, Dr Luckin recommends adopting the approach of providing clear, strenuous, explicit advice about what is safe and what is not safe.334

303. BSS Jackamarra, who has been stationed at the Burringurrah Community MFPF for more than four years, and was involved in the investigations for each of these matters, indicated that she agreed with Inspector Cox’s recommendation that the Summit Trail be closed for the hottest months of the year, but also supported the other trails remaining open at those times. BSS Jackamarra indicated that Mount Augustus is a beautiful place with a lot of traditional meaning for the local Aboriginal people, but it must be treated carefully. BSS Jackamarra suggested many of the ‘grey nomad’ tourists who come to Mount Augustus would still enjoy the options of walking Edney’s trail or other trails. She also supported guided walks being introduced by DBCA.335 BSS Jackamarra, who has lived in the area for many years and is used to the heat, noted that she has never personally walked up to the summit, at any time of year, although she has been taken there by helicopter. BSS Jackamarra has walked as far as the first chair, and commented that, in her opinion, it is a “nasty walk”336 and just reaching that chair was a little challenge and she would definitely not want to walk it in the summer months. In her opinion, if the walk was to be closed for periods, it would be best to have some form of gate installed across the path, as a visible physical indicator to people that the path is closed, rather than simply putting up information on the networks about the closure.337 BSS Jackamarra noted that the hottest months also coincide with the rainy season, so the rain itself limits the number of visitors to the area due to flooding causing road closures.338

304. Mr McCleary (who I discuss below in more detail) gave evidence he has been to Mount Augustus about 30 times and has never walked to the summit. He said the reason why he hadn’t was, in short, because “I don’t think I’m that stupid,”339 as he believes he would be one of the statistics if he attempted it. However, like other witnesses, Mr McCleary emphasised that there are many other interesting things to see, including the rock itself, without actually climbing it.340 Mr McCleary supported closure of the Summit Trail, at least at certain times of the day when temperatures are very high, noting that if people do not make an early start on the walk, then at certain times of the year the temperature will be extremely high in the heat of the day. However, Mr McCleary also suggested that closing the trail would be difficult

332 T 123.

333 T 130.

334 T 130.

335 T 197.

336 T 199.

337 T 200.

338 T 200.

339 T 211.

340 T 211.

[2022] WACOR 29 to manage from a practical point of view. Mr McCleary commented that there were very few tourists during the summer in any event, because “it’s just too damn hot for most of us,”341 with temperatures regularly falling in the 45 to 48°C range, and it’s not unknown for temperatures to reach 50 to 55°C. Like Dr Luckin, Mr McCleary suggested that an electronic sign at the start of the trail indicating the current temperature on the rock could be a good start.342

305. As noted at the start of this finding, there has been an increase in visitors to the area, and Mr Hammarquist indicated that in 2020, so the year before this inquest was held, there were approximately 20,000 visitors to the station. High season for tourist visitors is between April and October, although tourists do visit all year round. The Tourist Park is open every day of the year except Christmas Day, although the staffing levels vary from as low as three in the summer to as many as seven to nine people in the high season. Mr Hammarquist gave evidence that he believes since the DBCA has increased its presence at Mount Augustus, the DBCA staff have come to appreciate the increase in visitors for themselves and been surprised at the number of people completing the Summit Walk.343

306. Although the more temperate months in the middle part of the year provide the best experience, Mr Hammarquist indicated that he believes people can safely walk to the summit all year round, provided they listen to the advice and use common sense.

When the weather is warmer, the Tourist Park staff encourage visitors to get going very early in the morning, and in Mr Hammarquist’s experience “many, many people have a successful day hiking if they get out nice and early … and they’re back maybe 10 o’clock in the morning.”344 He believes the problem is when people do not take the advice on board. Mr Hammarquist also explained in his evidence that some of the visitors only come to the Tourist Park after they have already walked to the summit, so Tourist Park staff don’t always get an opportunity to provide all the relevant information.345

307. Mr Hammarquist emphasised that in his experience gained over many years, the number of people who come into difficulty, is only a very small percentage of the large number of visitors who come to Mount Augustus each year. Mr Hammarquist also believes that the number of older visitors attempting to complete the Summit Walk in the hotter months would be in the minority, and he believes from his observations that most of them tend to be younger backpackers, who are less at risk from the adverse effects of the challenging conditions.346

308. I note Mr Hammarquist described the more temperate months, when the climate is more acceptable for climbing, as May to the end of September/early October. This seems to be the general position, although I note that three of the deaths the subject of this inquest occurred in September. The Australian Bureau of Meteorology indicates that the monthly climate statistics for September at Gascoyne Junction show a mean maximum temperature of 28.4°C and mean maximum of 32.4°C in October. By December it is at 38.8°C and it hits a mean of 40.7°C in January and

341 T 214.

342 T 214.

343 T 261, 291; Exhibit 3, Tab 11.

344 T 262.

345 T 274, 276 - 278.

346 T 276.

[2022] WACOR 29 then stays high until April, when it drops to 33.1°C and drops as low as 23.3°C in July. Obviously, the maximum temperatures that were experienced by the Pollards and Greens in September 2019 were much higher than the BOM’s published mean for the month.347 I’m not sure if this was just unseasonal or an example of climate change slowly increasing our average temperatures, as anyone from Perth can attest to during this last summer as records broke over Christmas. However, Mr Hammarquist did give evidence that in 2021, the weather had been relatively mild up until early October.348

309. Mr Hammarquist also noted that this coincided with the school holidays and the Landor Races held at the Eastern Gascoyne Race Club, so the area had been busy with many people visiting Mount Augustus and walking the Summit Trail in what he described as “quite fair conditions.”349 Mr Hammarquist pointed to this evidence as a reason why he could not support Inspector Cox’s recommendation that the Mount Augustus Summit Walk Trail should be closed from September (through to March), suggesting that this is an extreme response that is not necessarily warranted. Mr Hammarquist suggested that a better system would be like the one implemented in Kalbarri. Mr Hammarquist was referring to the system in place at Kalbarri National Park, which has electronic stop/go signage in place where high temperatures are forecast, and he supported something similar being put in place for Mount Augustus, rather than full closure in certain months. Mr Hammarquist, along with other witnesses, considered Kalbarri National Park has set the benchmark for other national parks going forward.350

310. Noting the general belief of witnesses that a significant reason for the increase in visitors to Mount Augustus is the closure of Uluru to hikers, and Mr Hammarquist’s understanding most of the Tourist Park visitors intend to walk to the summit, closing the summit trail for a period of time will, no doubt, have an impact on the number of people coming to Mount Augustus at those times. This obviously will have a flow on effect for the Tourist Park and its business interests, which Mr Hammarquist acknowledged.

311. Nevertheless, Mr Hammarquist indicated that if a decision was made to close the Summit Walk from December or January to March, he would be open to that occurring, despite the fact his business would be affected, if it was done for the purpose of ensuring people’s safety and after consultation with all interested groups.

As Mr Hammarquist made clear in his evidence, he is a community-minded person with involvement in many aspects of the local area above and beyond his own business interests, including being President of the Upper Gascoyne Shire Council and President of the Eastern Gascoyne Race Club. He is open to a “common-sense approach that comes about collectively”351 as to how to manage the risks that the Summit Trail presents, and indicated he wishes to be a part of that discussion, noting that “local knowledge is invaluable,”352 whether it be from business people like himself or the members of the local Burringurrah Aboriginal Community. Mr 347 Australian Government, Bureau of Meteorology, Climate Statistics for Australian Locations, Monthly Climate Statistics. Gascoyne Junction, latest available data 21 March 2022.

348 T 276 – 279.

349 T 278.

350 T 268, 276 - 279.

351 T 279.

352 T 280.

[2022] WACOR 29 Hammarquist emphasised his belief that there needs to be a focus on good management of the park by DBCA, more akin to how the Kalbarri National Park is managed, including making good use of the rangers and also potentially volunteer camp ground hosts.353

312. Acknowledging all of the above, Inspector Cox spoke further to the first recommendation at the inquest. He noted that while the summer months are said to be the peak temperatures, he observed that in late October, a month after the deaths of Mrs Pollard and Mr and Mrs Green, he returned to Mount Augustus with others and noted that the area experienced temperatures around 40°C for five days in a row.

This meant it would have been at least 45°C on the summit trail in the heat of the day, but the summit trail was not closed by DBCA and anyone could choose to walk it, which apparently they did.354

313. Inspector Cox fears for other deaths in such circumstances, and he urges a closure of the summit trail for more than just the peak summer months, for that reason.

Inspector Cox noted that while the police will always respond when an incident occurs, from a police perspective, prevention is their main focus given the known difficulties of mounting an emergency response at Mount Augustus.355

314. In terms of people self-regulating, with better signage and information being made available for that purpose, Inspector Cox observed that many people will travel a long way to get to Mount Augustus for the sole purpose of walking to the summit.

This is particularly so now that Uluru is closed. Inspector Cox believes that, when people have invested considerable time, money and energy in getting there, they will not necessarily make good judgments when the weather is less than favourable. In his words, [n]ormal people just become a bit irrational and go, “Yes, I know it’s hot.

I know it’s 40 degrees, but I will still walk to the …. summit because that’s what I’m here for.”

315. Inspector Cox believes the only way to stop that kind of thinking is to close the summit trail for six months of the year in order to prevent any more deaths.356 He accepted that the other trails, such as Edney Trail, could safely remain open all year.357

316. While it was suggested that having more information available to people planning their trips, such as on the Internet, might help people to understand better the risks at different times of the year, Inspector Cox noted that in the case of Mr and Mrs Pollard, they had done research but it had not given them any real understanding of what to expect. He noted that if the photos and written information don’t convey the extreme heat and arduousness of the walk, even for people who are very familiar with Western Australia like Mr and Mrs Pollard, then for overseas visitors it would be even more difficult to convey that information. Inspector Cox believes most

353 T 279 - 282.

354 T 32 – 33, 38; Exhibit 1, Tab 1, p. 65.

355 T 32 – 33, 38.

356 T 32 – 33.

357 T 33.

[2022] WACOR 29 people from overseas would have no idea about the level of discomfort from the heat and the flies until they were up there and no understanding that there is nowhere to sit and rest in shade at any stage on the walk. They would be likely to underestimate the effects of extreme heat when hiking in such a location, having been unlikely to have experienced it before. Inspector Cox suggested that the risks involved are better understood and managed by experts, who fully understand the dangers.358

317. Further in support of closure of the Summit Trail, Inspector Cox noted that not only is there no help available for people who are on the summit, but when their companions try to go and get help, they must generally go well beyond the carpark to find it. The nearest community of people is the Tourist Park, which is 20 kilometres away on an unsealed road, and there are no emergency service providers based there.

The nearest emergency service providers are based at Burringurrah Community, and even there, they do not have the emergency medical services available that are necessary in many of these situations.359

318. Therefore, with a focus on death prevention, Inspector Cox felt strongly that the only way to ensure that more deaths like these do not occur is to close the trail in the hotter months. Inspector Cox gave evidence that he believes if we simply leave it up to the members of the public, “some of them won’t make the right decisions.”360 To underscore this view, Inspector Cox referred to the events following the deaths of Mrs Pollard and Mr and Mrs Green. Inspector Cox noted that the night after recovering the bodies of Mrs Pollard and Mr Green, and while they were still yet to recover Mrs Green’s body, Inspector Cox had people at the Tourist Park asking him if they could walk the Summit Trail the next day. He explained the police still had to walk up and recover someone who had passed away from the heat, and yet these people were undeterred and persistent in their mindset that they wanted to be allowed to walk up as soon as possible.361 The WA Police had powers as coronial investigators under the Coroners Act to restrict access to the trail while they were still recovering Mrs Green’s body, but once that had been completed their jurisdiction ended. The only agency with any ongoing authority to restrict that access is DBCA.362 DBCA has the power to close trails on Mount Augustus in certain situations under regulation 44 of the Conservation and Land Management (CALM) Regulations 2002, subsidiary to the Conservation and Land Management Act 1984, which is done with physical signs as well notifications on the webpage and social media.363 I understand it was closed by DBCA at the police request when they were recovering Mr and Mrs Green and then for a few days further until a DBCA staff member could personally review the trail.364

319. It was suggested at the inquest by some witnesses that a formal closure of the summit trail might not be the solution that Inspector Cox anticipates, as it would be impossible to monitor and enforce it, given the limited amount of staff presence at the site. However, Inspector Cox noted that the particular kinds of walkers that are the key focus of the recommendation are retired people who are generally law358 T 34 – 35; Exhibit 1, Tab 1, pp. 64 - 65.

359 T 33.

360 T 37.

361 T 37 – 38.

362 T 38.

363 T 348; Exhibit 3, Tab 16.

364 T 334.

[2022] WACOR 29 abiding citizens and would be likely to respect any such direction. Further, they are the kind of people who are more likely to plan their trip in advance, and would therefore note the closure and plan their trip around those dates. This would be preferable to making closures on an ad hoc basis, depending on weather forecast, which would affect people who had already made the long journey and who might then potentially be more likely to ignore the closure.365 It has also been submitted that closing trails based on the daily forecast temperature “would place an enormous onus on park staff.”366

320. I note that the DBCA appears to have used this power, since 10 November 2021, to close the Gully Trail component of the Summit Trail walk, which was shortly before this inquest commenced. I understand from my own review of the DBCA website that the closure was still in place at least in May 2022.367 I gather, as well as information being placed on the website about the closure, the DBCA also puts up signage to inform visitors at the site that the trail is closed.368 This is somewhat different to the talk of closing trails generally, as the Gully Trail is just one component of the Summit Trail, so it is not a case of restricting access entirely to the area.

321. It was also put to Inspector Cox in questioning that an alternate option might be to close the trail at a certain time of day in the summer months, such as from 6.00 am or 7.00 am. I am informed something similar is currently in place in parts of the Kalbarri National Park, with the Loop Trail closed under the CALM regulations after 7.00 am during the warmer months from November to March inclusive, making it illegal for visitors to commence hiking the trail after 7.00 am.369 Inspector Cox expressed his personal opinion, that such a measure would not be sufficient to prevent further deaths, as even if someone has left to climb the summit trail at 5.00 am, it is at least a three to four hour return trip at a minimum, and more like six hours for many people, so by the time the person has reached the summit and is descending, there is a high chance the temperatures will be very hot by that time if it is forecast to be 40°C that day, which would put lives at risk.370 Inspector Cox noted that the expert report of Dr Luckin has suggested that anything over 36°C could mean walkers are putting their lives in danger.371

322. It was submitted on behalf of DBCA that there is a balancing exercise that must be conducted between allowing visitor’s access to an attraction in a reasonable way and respecting the rights of the Tourist Park to continue to operate, weighed against visitor risk management and ensuring visitors’ safety.372 Dr Luckin had correctly identified in his report the tension between the desire of the police and some others to protect people by closing the Summit Trail and the desire of the DBCA, Tourist Park operators and others to allow tourists access to the attraction as safely as possible. Dr Luckin made several suggestions for ways that balance might be achieved, including

365 T 43 – 44.

366 Exhibit 3, Tab 16, p. 31.

367 https://alerts.dbca.wa.gov.au/home/index#45ddaf35-0ad4-4902-bbb7-ae237e38eede; . Mount Augustus | Explore Parks WA | Parks and Wildlife Service (dpaw.wa.gov.au)

368 T 51.

369 Exhibit 3, Tab 16, p. 29; https://parks.dpaw.wa.gov.au/park/kalbarri#yoursafety.

370 T 52.

371 T 52.

372 T 303 – 304.

[2022] WACOR 29 closing the walk during the hottest months or erecting a solar-powered electric sign incorporating a temperature-measuring device displaying a high-risk-warning at a temperature of 36°C and advising that the Summit Trail is closed when the temperature reaches 38°C. However, Dr Luckin acknowledged that these limits underestimate the effective temperature on the trail and do not allow for the effect of reflected heat from the rocks.373

323. Superintendent Beer, who was in court for Dr Luckin’s evidence, indicated that while Dr Luckin is correct that people would be physically able to ignore any closure if they chose to do so, in Superintendent Beer’s experience, most of the people who visit Mount Augustus are older, compliant people who will abide by any directions.

That includes the four deceased who are the subject of this inquest. Superintendent Beer supported Inspector Cox’s recommendation for a formal closure of the Summit Walk for certain periods, and suggested that if people are doing their research and see that it is closed for certain months, they will plan their journey accordingly.

Superintendent Beer suggested that the benefit of a formal closure is that it takes the decision away from people, and he believes it would make a significant difference in this case.374

324. Superintendent Beer acknowledged that there may be a commercial impact from closing the Summit Trail for certain times of the year, but suggested that more people would go there at the right time of year. In any event, the focus of the police is on death prevention, rather than any business implications.375

325. Mr Nicholson from DBCA noted in his statement provided to police in November 2020 that DBCA had reviewed heat management strategies in other parks such as Kalbarri and would be doing so for Mount Augustus National Park.376

326. Mr Nicholson gave evidence that he had personally walked the Summit Trail on 10 September 2019 as part of the annual visitor risk management inspection and he had noted that although the temperature was probably in the low 30’s, doing the walk felt hot, particularly due to the radiated heat from the hot rock in the sun, and there was not much breeze and nowhere to rest out of the sun. He noted that he drank quite a lot of water on the walk (having taken 7 litres with him as an experienced bushwalker with a good understanding of hyperthermia, so aiming for 1 litre per hour) and still felt quite thirsty when he got back, so it impressed upon him how people might underestimate the impact of the heat on that walk.377

327. Mr Nicholson indicated that from his perspective, he would not be opposed to the Summit Trail from December to February each year, noting that there are few visitors at that time due to the weather and, therefore, DBCA would not be disappointing too many visitors to the area. From his personal experience, he considers those months to be too hot to walk the Summit Trail as well. A closure over that period would also allow DBCA to better manage their resources to focus on 373 Exhibit 3, Tab 13.1, p. 4.

374 T 154.

375 T 164.

376 Exhibit 3, Tab 3.

377 T 305 - 308.

[2022] WACOR 29 maintaining a better presence at Mount Augustus the other nine months of the year.378

328. In terms of any broader closure, such as the September to March period suggested by Inspector Cox, Mr Nicholson expressed the view that while visitor safety is an important part of managing Mount Augustus, Parks and Wildlife also have a responsibility to provide recreational experiences for people and provide commercial opportunities for people in association with the parks. He noted that in 2021, temperatures in September and October were generally quite mild and did not prevent people safely walking the Summit Trail. Therefore, in balancing the issues of visitor safety and allowing broad access to our national parks and their recreational opportunities, Mr Nicholson suggests a shorter closure is the more appropriate option.379

329. As to a day-to-day temperature closure system, Mr Nicholson suggested it would be difficult to manage and might give walkers a false sense of security, as a temperature of 28°C may still result in very hot conditions on the mountain. He queried what temperature might be set then as the safe limit? He also suggested that pre-visit information is more important, to allow people to plan to visit at the right time of year, as he believes once people have reached the destination, they will be very intent on doing the walk and might be difficult to dissuade.380

330. Mr Phillips had considerable involvement in the changes implemented at Kalbarri National Park, and he indicated that similarly to Mount Augustus, it can be a pleasant temperature in Kalbarri, but become significantly hotter in the National Park and then extremely hot in the gorge. That is why they have implemented the live temperature gauge there. He noted that the timing coincided with a remote weather station being sited in the park for fire management purposes, and DBCA took advantage of that opportunity to get a temperature sensor placed in the gorge and then the temperature gauge in the carpark could be linked to that sensor in the gorge via mobile phone data, allowing for real time temperature information.381

331. Mr Phillips advised that, contrary to some of the evidence given, the gauge does not prompt a closure of the trail at certain temperatures. Rather, based on information obtained about the temperatures at certain times of the year, DBCA has used regulation 44 to implement a closure of the trail after 7.00 am from November to the end of March. The option of closing the trail entirely over a certain temperature had been considered by DBCA, but was ruled out as it would have applied to about threequarters of the calendar year. Visitors are informed of the closure from 7.00 am on signage at the park and while DBCA understands this will not stop all walkers, the pedestrian counter information they have obtained from the trail has shown that 75% of visitors comply with the direction and commence their journey before 7.00 am, which generally has them back in the carpark by 11.00 am, before the full heat of the day.382 Mr Phillips gave evidence that based on this successful trial, he can see the benefits in implementing a similar system at Mount Augustus and Karijini.

378 T 320.

379 T 336.

380 T 336 - 337.

381 T 366 – 368.

382 T 367 – 369; Exhibit 3, Tab 16, pp. 29 – 30.

[2022] WACOR 29

332. On the other hand, Mr Phillips does not support widespread closure of the Summit and Gully Trails, as proposed by Inspector Cox. Mr Phillips believes there are other ways to manage risk, based on the data they are getting out of Kalbarri, and other possible options such as guided walks by the local traditional owner rangers. Mr Phillips noted that these kinds of walks are consistent with the dual purposes of conservation and protection of cultural values in national parks. Mr Phillips indicated that the idea of joint management of national parks with the traditional owners is about bringing cultural awareness for visitors and economic opportunity for Aboriginal communities and corporations, both of which could be met with a proposal such as the proposed ranger guided walks. Obviously, there is a lot more work to be done before such a concept can become a reality, but it appears the proposal at least meets the criteria that DBCA are looking for when planning joint management with the traditional owners for the future.383 However, I note that DBCA supports the guided walks be included as one option for visitors, with visitors still able to choose the option of a self-guided walk.384

333. Therefore the position of DBCA is that, given the unexpected boon of the State government funding for the Gascoyne District, which is going to lead to significant improvements in communications and other facilities in the area, it is premature to take the drastic step of closing the Summit and Gully Trails at Mount Augustus for six months of the year. Rather, DBCA wishes to see how the new strategies of improved signage, etc, may work to reduce the risk, learning from the experience of the changes put in place at Kalbarri, which are still relatively new, and obtaining visitor feedback through the increased ranger presence at the Mount Augustus national park.385

334. Mr Phillips did concede that the DBCA local emergency plan for Mount Augustus should be updated to take into account the permanent presence of rangers in the area during at least some of the year, which could allow the senior ranger to make some quick decisions about whether a trail should be closed following an incident, such as what might have occurred after Mrs Pollard’s death. This is hopefully reassuring news for Mr and Mrs Green’s family, who are understandably very concerned that no action was taken the morning after Mr and Mrs Pollard came into serious difficulty, which might have prevented Mr and Mrs Green meeting the same fate.386

335. In relation to the resistance of DBCA to seasonal closure of the Summit Trail, in Mr Phillips’ report it is indicated that the Department undertook research as part of the Kalbarri National Park review, which found that no similar park agencies across Australia close access trails based on temperature.387 However, I note that there are seasonal closures of conservation parks for other weather conditions. A quick search of the Purnunulu National Park webpage shows that on 17 May 2022, Wunaamin and Miluwindi Conservation Parks were closed until further notice for the wet season, with opening dates dependent on weather conditions. It appeared they had been closed from early January 2022.388

383 T 385 - 386.

384 Submissions filed on behalf of DBCA, WA Police, DFES and WACHS dated 17 December 2021.

385 T 396 – 397.

386 T 390, 401.

387 Exhibit 3, Tab 16, pp. 53 -53.

388 Purnululu | Explore Parks WA | Parks and Wildlife Service (dpaw.wa.gov.au) and Parks and Wildlife Service - Department of Biodiversity, Conservation and Attractions - Park Alerts System (dbca.wa.gov.au).

[2022] WACOR 29

336. While I accept that those weather conditions may be as there is no safe vehicle access as well as other issues, it just demonstrates that DBCA will close parks when they determine weather conditions make access unsafe for some reason.

337. I also note in an article titled “Risky Business” written by Mr Phillips for the DBCA magazine Landscope’s August 2021 edition, he noted that some “popular tourist sites around the world have been closed permanently or have limited access in an effort to reduce the number of injuries and deaths.”389

338. I accept that, perhaps because we live in a very hot country and have a general understanding that we will have to live with hot temperatures at times, temperature is often not seen by Australians as a barrier to undertaking activities, even when it probably should be. However, that does not mean that temperature should not be a factor that alters our behaviour in the future, particularly as we are often being told that the climate is changing and is only likely to get hotter from hereon in. At some stage, we are going to need to readjust our attitudes or there will be more deaths. I say this, because the evidence before me suggests that the incidents do not, as many people assume, predominantly relate to interstate and international visitors.

Consistent with this inquest, the general statistics suggest that about 75% of incidents “involve Western Australians exploring their own backyard.”390

339. In support of those comments, I note that in January 2019, it was reported that frequent, urgent warnings from Northern Territory police, paramedics and park rangers to avoid hiking during a scalding Central Australian heatwave had continued to be ignored. The Northern Territory were pleading with members of the public “not to put themselves at risk from the conditions after they had to rescue an experienced local bushwalker.”391 The 60 year old woman had been part of a bushwalking group, so with others undertaking the same activity, when she sustained an ankle injury and became dangerously dehydrated. The SJA manager for the region was quoted as saying, “You’re not only putting yourselves at risk but you’re also putting the rescuers who have to come and assist you at risk.”392 The incident had come shortly after an exhaustive search for a missing German tourist, who it seems was sadly found deceased a few days later, and only a couple of years after two other German tourists had died from dehydration and heat stress in the same area. Temperatures had soared to over 40°C at the time.393

340. In another news article on 31 December 2018, three adult visitors from the Philippines, with a three year old toddler in tow, were reported to have suffered heatstroke after attempting a walk without enough water in the Central Australian bush in the middle of a 45°C day. Bushwalkers were urged by Northern Territory park rangers to heed advice and not put their lives at risk during the heatwave.

Rangers had reportedly turned around a couple.394 389 Exhibit 3, Tab 16, Attachment 16.

390 Exhibit 3, Tab 16, Attachment 16.

391 NT emergency services plea for hikers to stop ignoring heat warnings in the Red Centre - ABC News.

392 NT emergency services plea for hikers to stop ignoring heat warnings in the Red Centre - ABC News.

393 NT emergency services plea for hikers to stop ignoring heat warnings in the Red Centre - ABC News.

394 Three tourists and toddler's lucky escape after suffering heatstroke while hiking in 45C outback - ABC News.

[2022] WACOR 29

341. Most recently, on 12 April 2022, it was reported that a 22 year old man had collapsed and died while walking the Larapinta Trail and two different groups of people required assistance for heat stress within a week while also walking in hot weather in Central Australia. It was reported to be a busier than usual start to the tourist season for the area and the temperatures were reported to be ranging from 30°C to nearly 36°C around that time, so not dissimilar to some of the temperatures reported in the deaths before me for consideration.395

342. I mention all of these examples to demonstrate that this is not an isolated issue to Mount Augustus and not limited to a particular period of time. It is also to emphasise that in all these cases, the emergency service responders are urging people to make better choices about when they walk, both in terms of the time of year and the time of day that they walk, as well as how they prepare for it, but year after year the same issues are arising in Central Australia and more deaths are occurring.

343. With that in mind, and taking into account all of the evidence before me, in my view the safest and best option that balances the need for visitors to access the national park and support the local communities against the huge difficulties faced by emergency responders, is to close the Summit Trail and Gully Trail for the months from 1 November to the end of February. The evidence is that this would only affect a small number of visitors to the area, who could still choose to access the many other trails in the area or might well be persuaded to visit at a different time if they are aware in advance those particular trails are closed. The proposal has the support of:

• the WA Police, who are the ones responsible for coordinating the emergency response and whose safety is often put in jeopardy having to conduct rescue missions on the trail,

• the traditional custodians, who are also often involved in the rescue operation even though they would not willingly choose to walk the trails in the summer months, and

• even Mr Hammarquist (whose business would be the most adversely affected) does not strongly oppose it for those months.

344. I accept that the proposal does not have the support of DBCA, who manage the National Park, but I also note that DBCA do not have a lead role in any emergency response and they have no real presence at the site in these months. While the lack of presence is used to support a submission that, therefore, there should be no closure, in my respectful view it really supports the opposite conclusion. While I accept that there may be issues with DBCA then monitoring that closure and ensuring the signs are in place, I’m sure this could be managed with some casual employment of the trainee rangers over this period, or some other solution could be found (noting that there are permanent DBCA staff all year round based in Denham who have responsibility for managing the Mount Augustus National Park all year round and could be sent to the area intermittently).396

345. For the other months that are on the cusp or shoulder, being September and October and March and April (noting that September was the month when the three most Larapinta Trail warning after hiker, 22, dies and paramedics rescue groups in crippling heat - ABC News 396 Submissions filed on behalf of DBCA, WA Police, DFES and WACHS dated 17 December 2021.

[2022] WACOR 29 recent deaths occurred) in my view the most appropriate resolution is to put in place a restriction the same as is currently in place at Kalbarri National Park in the summer months, namely that the Summit Trail and Gully Trail are lawfully closed after 7.00 am, so visitors are prohibited from commencing the Summit Trail or Gully Trail walks after 7.00 am.

346. I emphasise that I make these recommendations not only for the safety of visitors, but also for the safety of the emergency responders.

347. I do not suggest that either of these types of closures should be backed up by a permanent ranger presence at the trails. I understand that is the case at Kalbarri National Park,397 but that it is not feasible for it to be put in place at Mount Augustus.

I believe appropriate signage at the site, as well as on brochures and maps and on the relevant webpages, would be sufficient to deter the bulk of visitors. I assume something similar is done in other parks such as Purnunulu National Park.

Recommendation No. 1 I recommend that the Hon Reece Whitby MLA, Minister for Environment and Climate Change Action, give consideration to directing the DBCA to close the Summit Trail and Gully Trail at Mt Augustus National Park from 1 November to the end of February each year, under the relevant regulations.

Recommendation No. 2 I recommend that the Hon Reece Whitby MLA, Minister for Environment and Climate Change Action, give consideration to directing DBCA to close the Summit Trail and Gully Trail at Mt Augustus National Park from 1 September to 31 October and 1 March to 30 April each year after 7.00 am each day, so that all visitors proposing to walk the Summit or Gully Trails must commence the walk prior to that time, unless they are participating in a guided ranger walk. Following on from Recommendation 1, if those trails are not closed during the months of November to February, then I would obviously recommend the same closure after 7.00 am should apply to those months unless visitors are undertaking a guided ranger walk.

397 Exhibit 3, Tab16, p. 56.

[2022] WACOR 29 2 – DBCA Staff on site to register and educate hikers

348. Inspector Cox suggested in his report that another appropriate recommendation would be for DBCA to provide a permanent ranger for the high season to manage all hikers on Mount Augustus.

349. At the time of these deaths, there were no DBCA employees based in or near Burringurrah. As noted above, the nearest DBCA office was in Shark Bay, which is a long way from Mount Augustus by anyone’s definition. Mr Hammarquist recalled that, from that time, DBCA attended the Mount Augustus area about five times between April and October (the high season). Mr Hammarquist also recalled a previous volunteer program run by DBCA for the high season, where volunteer ‘camp ground hosts’ managed by DBCA stayed at the Tourist Park for extended periods and provided information and advice to visitors to the Mount Augustus National Park. Prior to it stopping in about 2018, Mr Hammarquist believed the volunteer program worked well and his son David also supported the program, although David suggested the camp ground hosts would benefit from a uniform or some kind of official attire, so tourists would be more likely to head their warnings and advice.398

350. Inspector Cox and Mr Hammarquist both expressed the view that DBCA should be more involved in the ongoing management of tourists at Mount Augustus. Mr Hammarquist noted that, around the time of at least the later three deaths, not only did they not have DBCA staff providing verbal information to visitors, but they had also been slow to provide the DBCA trail maps to the Tourist Park office. Mrs Ansell mentioned this in her evidence.399 Mr Hammarquist emphasised the importance of the maps, as there is no internet service at the Tourist Park, so people cannot go online and look at the information on the DBCA website once they are there.400

351. Since these events, a DBCA employed Senior Ranger has been relocated to Burringurrah Community to manage the newly employed trainee Traditional Owner rangers. The DBCA manager resides in the Burringurrah Community during the six months of the high season. The ranger will apparently return to the Denham office for the other six months of the year and the trainee rangers will not be employed during the summer. While based at Mount Augustus during the peak season, the Senior Ranger will be responsible for day-to-day management of the works program for Mount Augustus National Park, including the Visitor Risk Management Program for the park.401

352. BSS Jackamarra gave evidence that the change of having permanent DBCA staff in the area, at least during peak season, is a positive one. She described the change as “amazing”402 and “a catalyst for many good things.”403 Mr David Hammarquist also indicated that he believes having the rangers at Mount Augustus regularly has been an integral part of ensuring safety and death prevention in more recent times.

However, Mr Hammarquist expressed the view that the continued DBCA presence 398 Exhibit 3, Tab 11 and Tab 20.

399 T 101; Exhibit 3, Tab 11.

400 Exhibit 3, Tab 11.

401 T 318; Exhibit 3, Tab 16, p. 54.

402 T 204.

403 T 204.

[2022] WACOR 29 needs to also be in the low season, not only the high season, noting that these deaths did not occur in the peak season but rather in the shoulder/low season as the weather is warming up. Mr Hammarquist commented that when the park is busy, there are people regularly climbing up and down the summit trail and they can look after each other, but there are much fewer people on the trails as the weather warms up. For that reason, Mr Hammarquist suggested there is a demand for the rangers’ services at these times, as much or even more than when the park is busy.404 Mr Hammarquist also supported the reinstatement of the DBCA volunteer camp ground hosts and indicated that they have a caravan site available at the Tourist Park for that purpose, if it was required.405

353. Mr Nicholson gave evidence that when visitation is extremely low over summer, DBCA has to make a decision whether it is really worthwhile having staff members based at Mount Augustus. However, he indicated there are some plans for a mobile ranger to be employed to work anywhere in the Shark Bay District, but mainly between Mount Augustus and Gascoyne Junction, over the full year, potentially also filling in and relieving when staff are away, which would then give the DBCA more options and flexibility to have a ranger at Mount Augustus more of the year if the demand was there.406 Noting he provided some support for at least a three month closure of the Summit Trail from December to February, then that could perhaps assist with the mobile ranger being present more in the shoulder months. Mr Nicholson also indicated support for reinstating camp ground hosts at Mount Augustus, as a fantastic way to disseminate information easily to people at the Tourist Park.407 This initiative was also supported in the submissions filed by DBCA.

The agency indicated in its submissions an intention to seek expressions of interest from volunteer camp ground hosts for the peak period during 2022.408

354. Mr Nicholson also supported Mr Mallard’s proposal for guided ranger walks, noting that DBCA is very supportive of having some sort of commercial operation for guided walks by the traditional custodians, which could also assist visitors to understand the importance of Burringurrah as a sacred place. However, Mr Nicholson indicated that Parks and Wildlife take the view that walkers should be able to walk independently as well and take the low-cost recreation option. Therefore, he would see the guided walks as an additional option to be made available to visitors, rather than replacing the current free and independent unguided access option.409

355. BSS Jackamarra, who has worked for over four years at Burringurrah Community and always worked closely with the local community, indicated that the local knowledge of Mr Snowball and the other rangers greatly assists her and the other police officers when searching at Mount Augustus, and she hopes in the future that they can have their expertise as traditional owners and assistance formally incorporated into searches that occur on traditional lands.410 BSS Jackamarra also supported any way that the rangers, who are very skilled and knowledgeable about the country, or other members of the local Aboriginal community, including the 404 T 263, 267 - 268; Exhibit 3, Tab 20.

405 T 268.

406 T 318 – 319.

407 T 338.

408 Submissions filed on behalf of DBCA, WA Police, DFES and WACHS dated 17 December 2021.

409 T 321.

410 T 196.

[2022] WACOR 29 suggestion of providing guided walks to the summit, although she noted that it would require a lot of planning and training before that could happen in order to get the business up and running.411

356. I note that in relation to the assistance that rangers could provide to police with searches during the summer season, when the trainees are not contracted, Mr Nicholson indicated that DBCA would be willing to mobilise the rangers and pay them overtime for their work in those circumstances if they are willing to assist with the emergency response, rather than have them have to assist as volunteers.412 Mr Phillips agreed that the rangers are an invaluable local resource in these circumstances, and should be utilised wherever possible.413 This is important, as it means that DBCA has a useful local resource that they can provide at an early stage to support an emergency response, something that would be of great assistance to BSS Jackamarra and the other officers who work at the community. In the peak season, when a full-time DBCA senior ranger is based in the area, they would also be directed to attend and assist where they could.414

357. As noted above, Mr McCleary is the CEO of the Shire of Upper Gascoyne, which takes in Mount Augustus, although DBCA is responsible for managing the site of Mount Augustus. In terms of Mount Augustus, the responsibility of the Shire extends only to the road networks that lead to and from Mount Augustus. The Shire’s administration offices are located in Gascoyne Junction, which is one of the indirect routes through which tourists heading to Mount Augustus may pass. The tourist information centre in the town therefore provides some information for tourists about Mount Augustus, as well as information that is made available on the Shire’s website.415

358. Mr McCleary gave evidence that the Shire had not traditionally had a lot of involvement with DBCA, but that had changed in the 12 to 18 months prior to the inquest. During that period, DBCA has not only installed a permanent and a number of trainee rangers at Mount Augustus National Park, but also put a permanent ranger and trainee rangers into Gascoyne Junction to start looking after the Kennedy Ranges National Park, which is another DBCA site within the Gascoyne Region. Mr McCleary gave evidence he understands some of this activity is relation to the DBCA working towards a joint management agreement with native title claimants for both national parks. Mr McCleary was enthusiastic about the change and indicated the Shire has provided office space to the DBCA ranger staff at Gascoyne Junction to assist them in establishing a presence in the region and to help grow the relationship between the two organisations and assist them in working together for the benefit of the region.416

359. It is clear from the above that Inspector Cox’s suggested recommendation of a permanent DBCA ranger in the high season has been fulfilled, with the addition of four trainee rangers.

411 T 201.

412 T 340 – 341.

413 T 373 414 T 342.

415 T 207 - 208.

416 T 210.

[2022] WACOR 29

360. I note that in the 2021-22 Budget Submission lodged by DBCA in relation to the $10 million election commitment, it mentions the possibility of using the trainee rangers to implement the planned works at Mount Augustus, which may mean there is opportunity to continue their employment over the summer as well, thereby increasing the DBCA presence at Mount Augustus throughout the year.417

361. Mrs Ansell suggested during her evidence that another way to improve communication and enhance any searching would be to arrange for distribution at the Tourist Park of a sticker or notice for walkers to leave on the dashboard of their car, providing some information about the occupants and their planned itinerary.418

362. BSS Jackamarra also supported Mrs Ansell’s suggestion that people be encouraged to leave their details on their cars. BSS Jackamarra, who is often the first police officer on the scene, indicated that any information they can obtain in the first instance helps them greatly, particularly if it can clarify that it is not simply people illegally camping on the rock.419

363. Mr Phillips, who had heard Mrs Ansell’s evidence, agreed that it is a relatively simple concept that is worth exploring further. He emphasised that it should not take the place of individuals notifying family and friends of their plans, as there is no guarantee that rangers will be in a position to check carparks on any given day.

However, Mr Phillips agreed that it would be very useful information for rangers and other emergency responders to have access to in order to quickly focus their search.

Therefore, without making any commitment to it, Mr Phillips indicated it was an idea that DBCA could explore.420

364. As I indicated at the inquest, in my opinion it is a very simple and practical suggestion, that I believe could be useful in all of our national parks. It is the kind of practical advice that DBCA can provide on its websites for all visitors, as an extra safety measure for people to take when leaving their cars in national parks, whether it be to go bushwalking, fishing, camping or other activities. I am informed that DBCA has already taken steps to develop a form that can be used across all the national parks it manages in relation to this suggestion. The form was guided by the “Outdoor Information Sheet” used by the Victoria Police, a copy of which was provided to the Court. It is described as a “Trip Intentions Form” and the Victoria Police form suggests that it be left at home with someone reliable.421

365. I have been provided with a copy of the ‘Dashboard Form’ (called the Emergency Information Form) developed by DBCA, and have been advised that the Department was intending in March 2022 to have it available at the Mount Augustus Tourist Park and also in a small box at the start of the Summit Trail, with information for visitors to complete the form and leave it on the dashboard of their vehicle. It is also available online on the website.422 The Department has also helpfully created a ‘Trip Intention Form’ based on the Victoria Police form of the same name, which it is 417 Exhibit 9.

418 T 96.

419 T 198.

420 397 - 399.

421 Submissions filed on behalf of DBCA, WA Police, DFES and WACHS dated 17 December 2021, Attachment 1.

422 Letter from DBCA to Coroners Court dated 10 March 2022.

[2022] WACOR 29 suggested that visitors leave with a reliable friend, family member or responsible person. The Department is extending the advice about the Trip Intention Form to its websites for the Purnululu, Kalbarri and Stirling Range National Parks, as well as Mount Augustus.423

366. I am pleased to see the Department taking the initiative with these proposals, and I consider they are a very useful tool for possibly preventing, and certainly assisting in, an emergency in these national parks.

367. Linking in with this issue is the Tourist Park ‘visitor book’. As I mentioned at the start of the finding, the Tourist Park used to run a visitor book for visitors who were proposing to walk the Summit Trail. It was unclear what the origin of the visitor book was, as Mr Hammarquist thought it had initially been established by DBCA, but the DBCA witnesses indicate this was not the case. There is a DBCA visitor book at the summit, for people to enter if they make it there, but it is a very different thing.

368. Mr Hammarquist gave evidence that, when he was at the station, he understood the visitor sign-in book was generally monitored to make sure that people who had signed in that they were going to walk the summit had signed out again on their return, and were safely back at the Tourist Park. He recalled incidents in the past when the Tourist Park staff had gone out looking in the dark for people who had not signed out. Often in those instances the staff had found people not on the summit trail, but instead they had gone to a different location to watch the sunset, so the matters had been resolved without incident.424

369. This did not, however, occur with Mr and Mrs Green, as no one went looking for them when they did not sign back in. Mr Hammarquist was asked if he knew why no alarm was raised at that time. He was unable to assist as he was not at the station at the time of Mr and Mrs Green’s deaths, but it was not in keeping with his understanding of the usual practice of the staff. In that sense, Mr Hammarquist said he thought it was “a good system but it’s not perfect.”425

370. Inspector Cox gave evidence that he considered the book as it was operating at the time of these deaths was “useless pretty much” as it wasn’t properly monitored, both in terms of people not always making an entry when they were intending to walk, as well as there being no regular monitoring of whether the people who did make an entry returned in an appropriate timeframe. Inspector Cox gave an example of checking the visitor book on a day when he was at the Tourist Park as part of this investigation and he noted that there were no entries in the visitor sign-in book, although he was aware a significant number of people had walked the Summit Trail that day. He also expressed his belief that the existence of the register created a false expectation in people that someone is going to go looking if they do not return.426 Inspector Cox gave evidence that he did not believe the monitoring of the visitor book was a proper function to rest with the staff of the Tourist Park, and that the 423 Letter from DBCA to Coroners Court dated 10 March 2022.

424 T 264 – 265.

425 T 264 – 265.

426 T 50

[2022] WACOR 29 monitoring of who is walking the Summit Trail should be done by the DBCA rangers who run the Mount Augustus National Park.427

371. Mr Hammarquist gave evidence at the inquest that he understood that since these deaths, the visitor sign-in book had been taken over by DBCA428 The DBCA witnesses made it clear that was not the case and the believe Mr Hammarquist is mistaken.429

372. Mr Nicholson gave evidence that he can see why it sounds like an attractive option for monitoring visitors to the area and allowing for a quick response when people get into difficulty. However, he also gave evidence that DBCA do not have the resources to operate such a system. Mr Nicholson suggested it is better to encourage visitors to notify friends or family of their plans so that they can raise the alarm. He agreed that a walker registration book can then be useful as a source of information for people to check, once the alarm has been raised, but did not consider it feasible for the book to be a mechanism for the alarm being raised in the first place.430 The same applies to the information on the dashboard.

373. Mr Nicholson also observed, similarly to Inspector Cox, that there is a problem that if a registration book is not managed and monitored correctly, then it can have a negative outcome by raising a false expectation that their absence will be noted, when in reality it generally will not. This is the concern raised by the Green family in relation to Mr and Mrs Green.431

374. However, as I raised with Mr Nicholson in his evidence, there is a difficulty in asking people to inform family and friends when mobile communication at Mount Augustus is currently so limited. He agreed it was problematic in the past, but noted that now that there is Optus and Telstra coverage at the Tourist Park, it may be less of an issue.432

375. Dr Luckin gave the example of mountain rescue registers, where any person going into various sections of the mountains in Africa must complete a rescue register on the way in and on the way out. However, those registers are checked regularly by rangers every day. Dr Luckin acknowledged that this would be more difficult at Mount Augustus, where there is nobody stationed in the area to monitor the register and see that people have failed to sign out on their return. However, Dr Luckin did suggest an electronic register might be a suitable alternative, which could be done via a mobile telephone and monitored remotely by a ranger or even police.433 As similar electronic system was also raised by counsel for Mrs Buske in questioning. Mr Nicholson indicated in his evidence that it was not something he had considered before, but with changes to technology, he accepted it was worth exploring further.434 Mr Nicholson also agreed that the system of a form for people to leave on their vehicle dashboard, as suggested by Mrs Ansell, has merit, provided people

427 T 39.

428 T 263, 265.

429 T 322, 349.

430 T 322 – 323.

431 T 324 – 325.

432 T 325.

433 T 131.

434 T 327.

[2022] WACOR 29 understood that rangers would not necessarily be checking the carparks at the end of each day.435

376. I note that information was also provided by DBCA that at a Class 6 trail in the Stirling Ranges, known as the Eastern Ridge Route, there is a visitor register that can be used to obtain relevant information to assist with a search, if a person goes missing, although it is not monitored. That walk is described as a wilderness experience, and obviously has significant risks with no trail markings, and presents significant risks that are different to other lower classed trails.436 It was indicated that something similar might be possible at Mount Augustus, although it would probably require the buy-in of the Tourist Park again to make it viable.437

377. Ultimately, what can be said is that the current system (if it is still in operation) of a visitor sign-in register at the Tourist Park office for people walking the Summit Trail is problematic and needs to be revisited. If it is to function solely as information that might be made available to emergency responders once a person is known to be missing, then that information needs to be made clear to the people making the entry, so that they are not given the false belief that someone is monitoring the book and will notice and raise the alarm if they fail to return. In my opinion, there is more DBCA could do in terms of at least considering the viability of an electronic register or a sign-in register at the base of the mountain, to at least capture some information in terms of how many people are walking the Summit trail and at what times, and obtaining information that can help the police in mounting an emergency response.

However, I leave that to DBCA’s own discretion to consider what might be feasible.

378. I understand from evidence heard at the inquest, as well as submissions filed after the inquest, that DBCA’s preference is for the Tourist Park to give consideration to removing the visitor book.438

379. Mr Hammarquist was contacted by Counsel Assisting after the inquest to clarify with him that DBCA did not have any involvement in or responsibility for the Tourist Park visitor book. Mr Hammarquist advised Counsel Assisting that he understood the ‘Visitor’s Book’ to be a record of guests at the Tourist Park and that there was also a ‘Summit Register’ that was managed by DBCA. Mr Hammarquist also referred to a whiteboard at the shop entrance, on which hikers can register their details prior to hiking the Summit Trail.439 A photograph of the whiteboard was taken by DBCA staff after the deaths in September 2020, and it shows that guests are encouraged to sign their name, vehicle registration, title and trail the hiker intends to hike.440

380. Mr Nicholson from DBCA also wrote to Mr Hammarquist to discuss further the issue of the visitor book, and confirm that it is not a DBCA document. Mr Nicholson also suggested that the Tourist Park should ensure that hikers understand if they write in the visitor’s book (or put their details on the whiteboard), that the Tourist Park staff make it clear that it will not be monitored and they should inform a family member or friend of their plans so that the alarm can be raised by them. Once the alarm is

435 T 326.

436 T 370.

437 T 350 – 351.

438 Submissions filed on behalf of DBCA, WA Police, DFES and WACHS dated 17 December 2021.

439 Submissions filed on behalf of DBCA, WA Police, DFES and WACHS dated 17 December 2021.

440 Exhibit 3, Tab 13.

[2022] WACOR 29 raised, the visitor book/whiteboard could then be used to obtain information by the emergency responders. Mr Nicholson also indicated that DBCA was seeking Mr Hammarquist’s permission to install signs at the Tourist Park to provide unambiguous advice to walkers that it is their personal responsibility to arrange for friends or family members to monitor their safe return and raise the alarm, if necessary, as well as including other hiker safety information and advice. This same information has been included on the DBCA website.441 3 – Mandatory use of Personal Locator Beacons for all walkers on the Summit Trail 8 – Increased Communication Capability

381. I have put these two recommendations together, as to a certain extent they are interconnected. If communication capability at Mount Augustus is improved, then the need for mandating a requirement for walkers to carry a Personal Locator Beacon (PLB) to a large extent falls away, although I note that there are still some advantages to PLB’s that should not be underestimated.

382. Superintendent Beer described telecommunications as the single biggest issue in any response, and the lack of mobile communications at Mount Augustus is a major impediment to police managing the emergency response there, with the remote location the other major challenge. Superintendent Beer described improving phone services as the number one way to mitigate this issue, and he considers PLB’s as a secondary option if mobile phone coverage is not available. Superintendent Beer noted that while PLB’s will pinpoint the location of the person, there is no ability to communicate with the person, whereas a mobile phone will allow a conversation to take place, which can provide the emergency responders with far more accurate information about what has occurred and what is required in response. Mobile phones are also fairly ubiquitous, so unlike PLB’s, people will already have them and are not having to be told to obtain one.442

383. Mr Hammarquist gave similar evidence, indicating that from the Shire’s perspective and in his role as a member of the steering committee mentioned below, their focus is very much on improving communications in the area to create mobile phone coverage. He observed that nearly every visitor to the Tourist Park has a mobile phone, so it is not unreasonable to expect that almost all parties will have a mobile phone with them when walking at Mount Augustus. Therefore, improving the mobile phone coverage will mean most people will then have the ability to use their phones to call for help if required. Nevertheless, Mr Hammarquist acknowledged that the project to improve communications in the area is still in the planning stage, so he would support increasing access to PLB’s in the interim through a loan or hire scheme, as a stopgap measure until the new mobile phone towers can be installed.443 441 Submissions filed on behalf of DBCA, WA Police, DFES and WACHS dated 17 December 2021 and Attachment 2.

442 T 151.

443 T 284 – 285.

[2022] WACOR 29

384. Mr Hammarquist expressed his opinion that the scheme should be optional, rather than mandated and indicated he was open to the Tourist Park assisting the DBCA with implementing a scheme whereby the DBCA could provide a quantity of PLB’s that could be held at the Tourist Park and provided on loan through the payment of a fee/refundable deposit in this interim period.444 Mr Nicholson, on behalf of DBCA, was also supportive of implementing this as a voluntary, rather than mandatory, scheme. He indicated that if DBCA can find some funding to purchase 30 or 40 PLB devices and the Tourist Park could administer the rental scheme, he would be very supportive of it being implemented.445

385. A/Supt Scott from the EOU advised that recent Federal upgrades in relation not automated mobile location means that when a person calls ‘triple 0’ and the caller stays on the line for more than 25 seconds, their GPS coordinates will be obtained and can be passed on by the operator to police. The EOU also has a system that allows them to send a text to the missing person saying, “WA Police search and rescue are currently looking for you. To provide your location, please press ‘okay’.” If they comply, that will then send their GPS coordinates to police. However, both of these systems require connectivity to work.446

386. All of the witnesses who gave evidence at the inquest supported improved communications at Mount Augustus, and believe it would have the ability to save lives. Although some concern has been expressed that more phone towers in the area might ruin some of the natural beauty of the region, it seems likely that the importance of good communication will outweigh these considerations. I note that it will not only allow people to call for help if required, but may also allow people to access up to date weather forecasts, that may give people a better gauge of the temperatures they may face.

387. There was evidence provided at the inquest that on 27 January 20221, the Hon Mark McGowan MLA, Premier of Western Australia, released the Plan for North West Central, which included an election commitment to invest $10 million for road and camping infrastructure at Mt August National Park. The proposal is to improve visitor safety, reinvigorate the visitor experience and develop opportunities to expand the tourism products on offer in the area. The money is apparently allocated in the context of a four year plan, with the first two years to be spent in planning and the funding then to be released by Treasury in Years 3 and 4, to allow for execution of that plan.447

388. A steering committee has been established to deliver proposals for how that money should be spent. Mr McCleary is a member of the steering committee for the project, along with staff from DBCA, the Gascoyne Development Commission, Mr Hammarquist and other interested parties and facilitators. Mr Hammarquist noted that there are five main focus points for the committee, in terms of how to allocate the funds, and the whole steering committee agreed that the number one priority was improving communication.448

444 T 272, 284 – 285.

445 T 330 - 331.

446 T 136 – 137.

447 Exhibit 9.

448 T 214 – 215, 266 – 267; Exhibit 3, Tab 18.

[2022] WACOR 29

389. Mr McCleary and Mr Hammarquist were able to speak to some of the plans that are in place to improve mobile communications at Mount Augustus for the future using some of that $10 million allocation in the State budget.449 Mr McCleary indicated that a lot of planning has already been completed. It was unclear who had arranged it, as Mr Hammarquist wasn’t sure, but there has recently been installed a 4G satelliteconnected small cell Telstra tower at the Tourist Park, which is providing reasonably good mobile coverage for about 8 to 10 km of distance from the homestead and Tourist Park area and does a reasonable amount of the eastern face of Mount Augustus. This has prompted the planners to consider whether the installation of two or three similar towers on the western side of the rock, along with two or three towers on the other side of the rock, might provide suitable coverage on Mount Augustus. Original costings for other options had been prohibitively expensive, but the current costings for this proposal suggests that three towers can be built for around $600,000, which is well within the scope of the $10 million budget. Mr Hammarquist indicated that DBCA had been assisting by recommending contractors who could assist with the works. There is a hope that it will provide very good coverage, although no system is perfect.450 I note that Mr David Hammarquist indicated prior to the inquest that they had recently had issues with their Telstra service, which had not been working for ten days. He noted it takes a long time for things to get serviced in the area of Mount Augustus due to its remoteness, so there will always be some issues.451

390. Consistent with the evidence of other witnesses, Mr Phillips from DBCA agreed that improving communications is an important part of managing risk at Mount Augustus. He advised that the Department of Primary Industry and Regional Development (DPIRD) is the agency that manages the Telstra and Federal Government black spot communication programme and DBCA has been liaising with DPIRD in relation to Mount Augustus. The earlier advice had been that only very expensive satellite technology would solve the issue. However, more recent advice received from DPIRD, in the two or three weeks prior to the inquest being held in November 2021, was the same as Mr Hammarquist and Mr McCleary had found, namely that there is now a much lower cost option of three small-celled towers available as a solution. Mr Phillips explained that each tower is basically a self-sufficient tower, to be placed at three locations mapped out by DPIRD’s communications person. It is believed that this will give mobile coverage on all the walk trails down the side of the national park that is not currently serviced by the Tourist Park’s Optus base station and relatively new Telstra facility.452

391. A statement from the Project Manager Regional Telecommunications for DPIRD signed 16 November 2021 and tendered at the inquest advised that the Minister for Regional Development has approved the State’s Regional Telecommunications Project (RTP) co-funding to upgrade the existing Optus base station at Mount Augustus Tourist Park to 4G from the existing 3G, which is scheduled to be installed by June 2022. As to the additional three small cells, DPIRD has sought quotes from Telstra, which suggest a “reasonable solution is achievable” within the funding envelope of $1 million that has been suggested by the steering committee. DPIRD is 449 T 214 – 215, 266 – 267; Exhibit 3, Tab 18.

450 T 214 – 215, 272 - 273.

451 Exhibit 3, Tab 20.

452 T 383.

[2022] WACOR 29 not a member of the steering committee, but will continue to provide advice, evaluation and contract management support as needed.453

392. This is consistent with other evidence heard at the inquest. Mr Phillips has been told figures around $500,000 per tower, which is similar to the $600,000 figure given by Mr Hammarquist and Mr McCleary, with the reduction of $100,000 due to Telstra contributing around 20% of the cost. Mr Phillips also understands that there is likely to be sufficient funds in the budget to commence with the proposal immediately, rather than in a couple of years, subject to consultation with the traditional owners and compliance with the various legislative requirements that affect national parks.

Mr Phillips understood at the time of the inquest that there was hope that all of these logistical details could be completed, and the project started by 30 June 2022.454

393. Mr Phillips observed that the completion of this project will be a “huge step forward”455 in terms of safety at Mount Augustus, as it will enable walkers to use the Emergency Plus app on their phones, which provides a detailed location point. The Department received permission from the national Triple Zero Awareness Work Group to promote the Emergency Plus app, and has now included this information in park brochures and on signage. There is also another app called “what3words,” which is managed by the New South Wales Fire Brigade for the national Triple Zero Australia services. In essence, it allows a person in difficulty who has mobile coverage to push open the app and then ring an emergency operator and tell them the 3 words on the app that will assist the operator to identify their exact GPS location.

Therefore, they will be similar to a PLB in the sense of providing emergency responders with a specific location to search. However, unlike a PLB, it requires more than simply setting of the beacon for a response to be mounted.456

394. Without mobile connectivity, which appears to still be some time away, the Personal Locator Beacons are the next best option. I also note that a PLB is not subject to the vagaries of the mobile network service, so they will work even when the mobile coverage doesn’t. Inspector Cox agreed that if they had full mobile coverage at Mount Augustus, it would make the PLB less of an essential item. but the advantage of a PLB is that it can provide a very accurate location for searchers, and it is monitored 24 hours a day, 7 days a week and doesn’t require the network to be operating.457

395. At the inquest, Inspector Cox indicated that, personally, he still supports personal locator beacons being mandated. He accepted that it might be a lot to ask an overseas visitor to purchase a PBL for $400 for one trip, which is why he suggested there be a loan system arranged through the tourist centre.458

396. A/Supt Scott discussed the benefits of PLB’s, which he considers to be very good as they generally have a battery life of five to ten years and once activated, are very accurate in terms of identifying the location of the person through the assistance of the Joint Rescue Coordination Centre. At the time of the inquest, A/Supt Scott had 453 Exhibit 3, Tab 18 [13].

454 T 383 – 384.

455 T 384.

456 T 384; Exhibit 3, Tab 16, p. 25.

457 T 53.

458 T 53.

[2022] WACOR 29 recently participated in a working group meeting with DBCA, AMSA and other partners to look at opportunities to possibly mandate the use of PLB’s in certain circumstances, or at least educate the broader community on how good they are and that they should consider using them, particularly if they are going into remote parts of Western Australia.459 Mount Augustus will be one of the sites being considered by the working group, as they are looking at high-risk environments. A/Supt Scott explained that one option they are looking at is a ‘park pass’ and if people are going into a park that is high-risk, then it would be mandated that they have a PLB before entering. A/Supt Scott gave evidence that some PLB’s cost as little as $300 now, and it is hoped that the fall in price will make their purchase more attractive and achievable for the average person.460

397. Cost is, of course, always an issue, and $300 may sound like a lot of money to many people for something they may never need to use. However, it should be remembered that people are expending money to travel to these places on holiday, so investment in their own safety should really be part of their travel plans. The enormous cost to the community of search and rescue missions is also relevant, when weighed against the small personal cost to an individual. A/Supt Scott also noted that the use of a PLB somewhere like Mount Augustus can move the focus of the operation from a “search to hopefully a rescue.”461 With that in mind, people are encouraged to register their PLB’s, so the JRCC is able to not only pinpoint the missing people, but also contact other family members and get a good idea of the people involved and their particular needs. A/Supt Scott mentioned the recent incident of the young family in South Australia who became stuck in the mud in their campervan and used their registered PLB to alert the authorities to their distressed circumstances, which resulted in a very quick response and a good outcome for the family.462

398. A/Supt Scott acknowledged that it might be difficult to police compliance, but he also noted that in his experience people who travel in regional Western Australia are generally very compliant with the rules, if they are aware of them. He believes if having a PLB was a requirement to get a park pass, the vast majority of people would make sure they had a PLB. There is the possibility of liaising with stakeholders, such as hire car companies, to assist with that compliance for interstate and international tourists.463

399. For this reason, A/Supt Scott also supports the proposal for a loan system for PLB’s at Mount Augustus, particularly until better communications are put in place, although his preference is for PLB’s to be made mandatory in high-risk areas like Mount Augustus.464

400. It was noted by A/Supt Scott that, even once the location of a person in distress has been identified, there are still significant challenges in getting the resources to that location if the person needs to be rescued, which is problematic given the short

459 T 137.

460 T 137.

461 T 138.

462 T 140.

463 T 139 - 140.

464 T 139.

[2022] WACOR 29 timeframes for survival in that harsh environment, but a PLB is one part of the puzzle.465

401. Superintendent Beer indicated at the inquest that he has no doubt that if the people involved in these deaths had been able to phone for help, the search and rescue operation would have been much more immediate. He noted that there are willing people at the Tourist Park to provide early assistance, as well as two police officers and nursing staff at Burringurrah Community, which is only half an hour away, so whilst they would not be able to send “the whole cavalry,”466 they could send a very quick and targeted response, which possibly could have led to a different outcome.467

402. The witnesses from DFES also supported the use of PLB’s to help narrow the search area for a person and prompt an earlier response, particularly where mobile phone access is limited.468

403. BSS Jackamarra gave evidence at the inquest that a few months prior, and elderly man had come into difficulty due to flooding and his vehicle tracker had been ruined on the terrain, but he had with him a PLB, which he activated. Police were notified of the activation and eventually arranged for the man to be rescued by helicopter and taken to hospital. She noted that as a result of the PLB, everything turned out all right on that occasion, which shows “how helpful they are.”469

404. BSS Jackamarra has had personal experience with the many communication difficulties at Mount Augustus, and she expressed her personal view that she was hopeful that the communication upgrades would prevent further deaths.470

405. Mr Phillips indicated in his report that DBCA considers that visitors are better off being informed of the need for PLB’s before they depart on a trip or holiday, rather than relying upon them being available in the national park. However, DBCA do currently hire out PLB’s in one national park, Purnululu National Park (where the Bungle Bungles are located), for hikers wishing to undertake the Picanninny Gorge trek, which is a Class 5 trail and an unmarked route with no facilities or directional signage and takes a minimum of one night and often two nights to hike. Hikers must be prepared and register at the visitor centre (which is open every day the trail is open – namely, early April to mid-October) before they commence and de-register again on their return. They are also required to have a satellite phone or PLB, so DBCA will hire one to them through the visitor centre if they do not have one of their own. With that scheme, there is a $30 hire fee and a $250 refundable deposit.

Mr Phillips indicated that DBCA are intending to discuss with the owners of the Tourist Park to determine if they would be interested in hiring out PLB’s to visitors to the park, as it would require their cooperation since there is not a permanent ranger presence when the Summit Trail is open.471

465 T 142.

466 T 164.

467 T 163 – 164.

468 T 172, 181.

469 T 199.

470 T 205.

471 Exhibit 3, Tab 16, pp. 53 – 54.

[2022] WACOR 29

406. I note that there was a very recent incident reported at Kakadu National Park on 13 May 2022, when a young man fell into a deep ravine and was injured and trapped in a tree. Fortunately for the young man, he was carrying a PLB, which he activated at about 5.00 pm. He was able to be rescued from a very remote location, although it took more than a dozen people, and over 11 hours, to reach him and get him to safety. He would have been waiting a lot longer if he hadn’t been able to activate his emergency beacon.472

407. A submission made on behalf of DBCA was to the effect that is highly unlikely that the use of a PLB would have prevented the deaths of any of the deceased in this case.473 I am not persuaded this is the case. If they had had the option of activating the PLB, I consider it very likely Mrs Buske and Mrs Pollard would not have left their spouses to go and seek help and there is no evidence to suggest they weren’t capable of making that rational choice. In Mr Buske’s case, this may have saved him from getting lost on the path. In Mrs Pollard’s case, she would not have been exerting herself and she could have been assisted by her husband’s knowledge of survival skills. We have very little knowledge as to what happened to Mr and Mrs Green, so it is simply speculation to say they could not have activated the device and earlier assistance could not have helped them.

408. In summary, there is no reason for me to make any recommendation in relation to improving the mobile communications at Mount Augustus, as those works are well and truly in train. My focus, therefore, is only on PLB’s in the context of a more short-term loan system, as well as encouraging people who are travelling remotely often to purchase their own.

Recommendation No. 3 I recommend that DBCA explore the option of the Tourist Park facilitating a short-term PLB loan scheme, similar to what is done in Purnululu National Park and with the stock of PLB’s supplied by

DBCA.

4 – Reclassify the Grading of the Summit Trail to a Grade 5 Hike

409. Inspector Cox had recommended that the Summit Trail, which was graded as a Grade 4 track, be upgraded to a Grade 5 track (which already applied to the Gully Trail part of the walk). It was indicated at the inquest that the DBCA had accepted the validity of that recommendation, and plans were already in place to make that change.474 There is, therefore, nothing more that needs to be said about this proposal.

472 https://www.abc.net.au/news/2022-05-13/kakadu-national-park-nt-man-rescued -after-50m-fallpolice/101065078.

473 Submissions filed on behalf of DBCA, WA Police, DFES and WACHS dated 17 December 2021.

474 T 55, 380.

[2022] WACOR 29 10 – Increased Warnings on all Mount Augustus websites 5 – Increased Permanent Danger Signs on all trails

410. I have put recommendations 10 and 5 together, as they are related in terms of what information potentially will be read by visitors before they commence the walk. The website information is obviously important, as it allows visitors information to assist them in planning their journey appropriately, in terms of when to come and what they wish to do, while the signage at the national park will layer upon that early information.

411. Inspector Cox expressed his opinion at the inquest that the information on the websites should be more explicit than simply referring to possible risks and dangers.

He suggested that the website should say that multiple people have died at Mount Augustus, as he believes this very explicit information is far more likely to make people think twice about making the journey.475

412. Mrs Ansell indicated that she had seen some warnings on the DBCA website, but not on the other websites, despite accessing the Shire of Carnarvon’s website for relevant information. Mrs Ansell agreed that warnings on all relevant websites are “absolutely essential”476 to warn tourists planning a trip about the known risks.

413. Mrs Ansell also suggested that the warnings should be very clear about what is meant by “fit” in terms of the kind of physical fitness required for the various walks.477

414. Ms Greenwood, who had passed the Greens on their ascent, told police that she and her partner had felt unprepared for the reality of the summit hike, based on the pamphlet available at the Tourist Park at that time and the information available on signage at Mount Augustus. She suggested that updated information should “stress the seriousness of the conditions, for example, the importance of being properly prepared (hats, sufficient water, beginning the hike early, not to start the climb after a specific time).”478 Ms Underwood also suggested that consideration should be given to revising the minimum time estimated for the hike to the summit. In her past experience, Ms Underwood and her partner would normally complete a hike well within the estimated given time, but unusually, the Mount Augustus hike took them much longer than they had anticipated.

415. There was evidence the Buskes, the Pollards and the Greens had all done research over the Internet before their trips, and thought they had planned accordingly. It seems clear the information provided to them did not provide an adequate understanding of the risks involved.

416. Dr Luckin commented in his evidence that it needs to be very apparent in the literature that this is a long hike, that it’s going to take at least six to eight hours, and it should be explicit that if they are not familiar with very rough terrain and very hot,

475 T 63.

476 T 98.

477 T 100.

478 Exhibit 2, Tab 14 [36].

[2022] WACOR 29 very arid environments then they should not attempt the walk. Dr Luckin believes it also needs to be stressed that there is no possibility of rescue if they get into trouble while on the walk. Dr Luckin believes this kind of information would help people who carefully research beforehand to assess the risk well before travelling to Mount Augustus.479

417. Dr Luckin suggested that the online information on the DBCA/Parks and Wildlife tourist information sites should be rewritten, to include detailed information on the requirements for walking the trails safely and a clear description of the temperatures and reflected heat which are to be expected.480 Dr Luckin suggested that the warning should indicate that the “Mount Augustus summit is a very strenuous walk, taking at least 6 hours for the fittest. Do not attempt the Summit Walk unless you are wellrested, fit, healthy and experienced.”481

418. Dr Luckin also emphasised that the information about the large amount of water that should be taken and consumed is extremely important, as this information is “a tried and proven basis of staying alive.”482 This also includes informing people that they should be passing urine regularly on the way up and down, as a sign of being well hydrated.483

419. Dr Luckin commented that people who are not experienced in this type of environment are very likely to underestimate the difficulty of the walk and will not carry enough water. They are also more likely to push on when dehydrated and overheated, not realising that the walk up to the summit is the easier part, and so they will fail to appreciate the danger that they are in until it is too late. By the time they are descending, they are already hot and tired and quite possibly dehydrated and now they are walking in the hottest part of the day on a more difficult terrain and they are more likely to fail to recognise the path and move off path. They are also less likely, especially if from overseas, to have ensured that a responsible person knows where they are going and is in a position to check whether they have safely returned.484

420. Mr McCleary indicated that the Shire understands the need for accurate information to be distributed to potential visitors to Mount Augustus in terms of the average temperature, whether the ‘rock’ is open or closed and other relevant information. He noted there are many entry points to the site, including Gascoyne Junction where the Shire is based, but also many other towns like Carnarvon, Meekatharra and others.

Mr McCleary noted that the information can be provided at the tourist information centres in those towns, as well as on the Shire’s website, in addition to what is available on the DBCA website. Mr McCleary indicated that he would be happy if the information came from DBCA, but the Shire was used as a tool to distribute it more widely. Mr McCleary also suggested that people at the tourist centres could provide more personal and current information, and hopefully guide people away from taking dangerous risks.485 However, Mr McCleary also commented that in his experience tourists can be funny, and once they “get a thing in their head that they’re

479 T 110.

480 Exhibit 3, Tab 13.1, p. 18.

481 Exhibit 3, Tab 13.1, p. 13.

482 T 118.

483 T 118.

484 T 109 – 110.

485 T 210 – 211.

[2022] WACOR 29 going from point A to point B and going to do something … it’s pretty hard to convince them not to do that.”486 This comment underscores the need to get accurate information out to potential visitors early, when they are planning their visit rather than when they are on their way to Mount Augustus.487

421. Mr Nicholson accepted that DBCA has a responsibility to provide helpful and accurate pre-visit information and to provide warnings and information so that people can assess the risks. From there, he expressed the view that there is a level of personal responsibility that then rests on the individual to assess their capacity to manage those risks.488

422. Mr Phillips gave evidence that one component of the trial at Kalbarri National Park has been the creation of flyers or brochures containing a very clear message of the dangers of heat, which is distributed through the local tourist visitor centre and the local accommodation providers, to see whether this form of information will have an impact on visitors. Once data is obtained on the effectiveness of this form of information dissemination, they can look at possibly implementing it in other places.489

423. Mr Phillips gave evidence at the inquest that DBCA has recently engaged the Curtin University Consumer Research Lab to conduct some research to assist the Department in developing a communications plan for a public safety campaign around key themes including hydration, falls and swimming/drowning. They are doing consumer and marketing testing on some concepts on signage and messaging that will communicate risk in language that is consistent and easily understood by visitors. Mr Phillips noted that this relates to both information available through media and on websites, as well as on signage.490

424. Information provided at the inquest indicated that the signage at the time of these deaths indicated that the Summit Trail was 12 kilometres in length and walkers should allow six hours, noting it is a long difficult hike ascending over 650m above the carpark and walkers will be exposed to sun, wind and rain. Relevantly, the warnings at the time recommended people start out early, but no timeframe was given for what ‘early’ meant and each person should drink 3 to 4 litres of water to avoid dehydration. Protective clothing was also recommended, as well as walking only as fast as the slowest member of the group and taking rest breaks. There appears to have been no mention of possible extreme temperatures and no mention of previous deaths on the trail.491

425. Dr Luckin suggested that the signage at the Flintstone-Beedoboondu carpark be replaced with signage listing specific warnings. As noted above, Dr Luckin suggested the following, very blunt, warning:492 The summit hike is a very strenuous and long walk. MINIMUM 6 – 8 hours.

486 T 211.

487 T 211.

488 T 315.

489 T 368; Exhibit 3, Tab 16, p. 30.

490 T 379; Exhibit 3, Tab 16, pp. 25 - 26.

491 Exhibit 3, Tab 13.2.

492 Exhibit 3, Tab 13.1, p. 6.

[2022] WACOR 29 It is NOT SUITABLE for people with limited or no experience of harsh conditions.

It is NOT SAFE for people who are not acclimatised to hot and dry conditions.

It is NOT SAFE for people with heart or lung conditions or diabetes.

426. Based upon the evidence Dr Luckin gave about the potential for dehydration to cause renal failure, and noting the near death of Mr Pollard, I also think it might be prudent to add diabetes to the list of conditions, which I have indicated in underlining above.

427. In addition, I suggest that there should be added the warning: It is NOT recommended for people over the age of 65 years. A number of recent deaths have occurred in relatively fit people of that age group who attempted the Summit Walk.

428. Dr Luckin also suggests the signage should indicate that people should carry a minimum of 6 litres of fluid per person if you attempt either of the summit trails, and drink 1 litre per hour, such as: Carry a MINIMUM of 6 LITRES of FLUID per person, and drink 1 litre every hour.

429. Dr Luckin expanded on this, to indicate that each person should drink one litre per hour and companions should watch each other to make sure they are drinking regularly. Walkers should note that if they do not pass urine at least once on the way up and once on the way back, they are not drinking enough water.493 Dr Luckin indicated that people should be encouraged to keep their water as cool as possible, preferably in insulated containers, as hot water discourages hot people from drinking.

If possible, some of the fluids should be an electrolyte solution or sports drink, but they should not contain caffeine as they increases heart rate and deceases cooling through the superficial blood vessels.494

430. However, it is also important to note that Dr Luckin indicates that “[a]dequate fluid alone will not prevent deaths on Mount Augustus.”495 So it is not enough to say that if people carry enough water, any person can safely walk up to the summit any time of year. Nevertheless, Dr Luckin emphasised that adequate hydration is critical to survival, and the signage needs to carefully explain why people need that volume of water. It also needs to make it clear that if a person can’t carry that amount of water (noting six litres is six kilograms in weight, and that is the minimum that should be carried) then the person should not be undertaking the walk.496

431. Dr Luckin indicated that the requirement to carry a minimum of six litres per person should apply at all times of the year at Mount Augustus, as even in the so-called cooler months between April to October, the temperatures are still hot, ranging in the mid-thirties, and the relative humidity is higher, with an average of about 68%. The higher humidity affects the body’s ability to cool, so the person will actually need to 493 Exhibit 3, Tab 13.1, p. 6.

494 Exhibit 3, Tab 13.1, p. 8.

495 Exhibit 3, Tab 13.1, p. 8.

496 T 118 – 119.

[2022] WACOR 29 consume more fluid. Dr Luckin expressed the opinion that to suggest to people that they could be less well-prepared in those months “would be doing them a disservice and increasing the risk of further deaths.”497 Dr Luckin indicated that if he were intending to walk to the Summit Trail at any time of year, he would carry more than 6 litres, as he would carry 6 litres in an insulated camel pack and then carry one or two water bottles that he would drink first, before they became too hot, and he would also use that water to cool himself by wetting his hat to cool his head and aid evaporation.498

432. Dr Luckin’s example of the kind of information that should be on a sign at Mount Augustus is set out below: The summit hike is a very strenuous and long walk. MINIMUM 6 – 8 hours.

It is NOT SUITABLE for people with limited or no experience of harsh conditions.

It is NOT SAFE for people who are not acclimatised to hot and dry conditions.

It is NOT SAFE for people with heart or lung conditions or diabetes.

It is NOT recommended for people over the age of 65 years. A number of recent deaths have occurred in relatively fit people of that age group who attempted the Summit Walk.

Temperatures on the trail can be up to 10°C hotter than at the base.

DO NOT ATTEMPT THIS HIKE if the forecast temperature is => 36°C or after 8.00 am, as the temperature on the trail will be extreme, and potentially fatal.

Carry a MINIMUM of 6 LITRES of FLUID per person and remember to drink regularly.

People have died on the summit trails, from dehydration and overheating.

Remember, this is meant to be an enjoyable experience.

IT IS NOT WORTH DYING FOR

433. Dr Luckin agreed with the suggestion that a permanent memorial at the carpark of the Summit Trail setting out the details of the lives already lost there, would be a very valuable and powerful testament, and the kind of warning that people will actually to take heed of, rather than more generalised warnings.499

434. Mr Snowball expressed a general concern about the age of the people he had seen attempting the summit. He has noticed that many of the people he sees walking to the summit are older people, who he believes “want to make it up there to the top ….

Just to say they’ve been up there.”500 Knowing the heat that can be experienced on the climb, Mr Snowball believes there needs to be more information provided to people about the heat before they attempt the climb, so that they can make a proper risk assessment.501 I note that Mr Snowball has been involved in all of the searches for missing people at Mount Augustus, so he knows both the types of people who are

497 T 120.

498 T 120 – 121.

499 T 129.

500 T 7.

501 T 10.

[2022] WACOR 29 getting into trouble and where they have got into difficulty. He was instrumental in finding Mrs Ansell, who was very fortunate to survive after getting lost overnight.502

435. Mr Nicholson gave evidence that DBCA have already installed new temporary signs that he believes are “quite confronting”503 and “fairly blunt,”504 which he considers to be a good thing as people are less likely to walk past without reading them. The signs were installed on or about 22 September 2020, in response to the spate of deaths a week or so before.505

436. Mr Phillips indicated he had done his own research after these deaths and had identified a few areas for improvement in the DBCA signage. He then had an opportunity to read Dr Luckin’s report. Mr Phillips said he didn’t disagree with Dr Luckin that a more direct and “in-your-face” message may be required for visitors to really get the message across. Indeed, he agreed that, “[w]e need to be blunt.”506 However, Mr Phillips explained that the message also needs to be consistent with other DBCA signage. Some fairly direct signage has been put in at Kalbarri National park showing information on the risks of heat stroke, which was the basis for the signs put in place at Mount Augustus in September 2020. The signage for Kalbarri and Mount Augustus could be altered consistently, but it requires some more work to be done by DBCA to determine how that message will be formulated.

437. Mr Phillips gave evidence once of his first major projects in his current role at DBCA was to deal with the rock fishing danger issue, following one of the many deaths that has occurred while a person has been rock fishing off the WA coast. Mr Phillips said he initiated discussions with the Department of Fisheries, Recfishwest, Royal Surf Life Saving and local government, and together they developed a coordinated approach so that the same signage with consistent warnings is in place wherever people are rock fishing in the State.

438. Similarly, Mr Phillips gave evidence that DBCA trails and communications staff are now developing a sign plan for Mount Augustus, including the Tourist Park, to ensure that the language is right, the images are right, and there are photo depictions to help everyone easily understand the message that is being conveyed about the risks. Mr Phillips indicated the plan is to have the new signage in place in time for the next peak visitor season,507 which is now. In terms of ensuring that signage is consistent with other parks in the State, Mr Phillips indicated that, after listening to the evidence at the inquest, he has identified information such as ‘carry one litre of water per hour, per person’ as a simple message that can be effective for Mount Augustus and equally for other trails. Mr Phillips indicated he still needed to consult with the Department of Health to ensure that the advice is consistent with State government health advice, but he assumed the advice will be consistent with Dr Luckin’s advice.508

502 T 24.

503 T 314, 504 T 314.

505 T 349.

506 T 379.

507 T 380.

508 T 380 – 381.

[2022] WACOR 29

439. Mr Phillips also suggested that visitors to Mount Augustus should be encouraged to try some of the other trails first, before attempting the Summit Trail, so that they can get some experience of the conditions and gauge their ability to attempt the harder hike.509

440. I was later informed that, as DBCA had still not received the advice from the Department of Health in March 2022, the Department of Health had decided to follow Dr Luckin’s advice and implement the recommended one litre per hour water intake message, unless and until it hears to the contrary from the Department of Health. In line with that position, DBCA has redesigned one of its graphics to depict camel style water backpacks, together with water bottles, and a message that hikers should drink 1 litre, per person, per hour. The graphic will be used on updated heat flyer warnings for visitors and new trailhead signs to be installed for all trails at Mount Augustus.510

441. The trail signage works have progressed significantly since the inquest, and I was advised in late March 2022 that DBCA has reviewed and updated all the signage associated with visitor information and trails in Mount Augustus National Park. It was intended that they would be installed in early April 2022, so I assume that has occurred. I am informed the key changes and additions for the sign include the new water graphics and Dr Luckin’s advice about one litre of water per hour of walking, as well as information about the cooler months best suited to hiking (being May to August) along with information about attempting shorter hikes before considering the longer hikes, information about the limited communication options and recommendation to carry a PLB or satellite phone and also to tell a responsible person about their plans.511

442. Importantly, for the Summit Trail, the new signs include the key messages:512

• Full day extremely difficult hike;

• If you can’t carry at least 6 litres of water per person – do not attempt this hike;

• Inclusion of the Emergency Plus app information;

• Inclusion of a photograph showing part of the actual Summit trail;

• Reference to walking in the cooler months (May to August);

• Message to start no later than 30 minutes after sunrise;

• Reference to filling out the Summit Hiking Form (for their dashboard); and

• Directing visitors to carry a PLB or satellite phone and advising mobile phone coverage is limited.

443. I note that the signage refers to the fact that heat stress can kill and reference to the potentially extreme temperatures at certain times of the year and the Summit Trail does indicate that if people can’t carry six litres of water per person, they should not attempt the hike. However, I think what is absent from all of these messages is notice that a number of people have recently died attempting the Summit Walk. Hopefully, if the suggestion to erect a memorial at the base of the Summit Trail (as discussed during the inquest and mentioned in my conclusion below) is implemented, then that very clear warning about the real dangers that hiking the Summit Trail presents will

509 T 382.

510 Letter from DBCA to Coroners Court dated 10 March 2022, Attachment 3.

511 Letter from DBCA to Coroners Court dated 23 March 2022.

512 Letter from DBCA to Coroners Court dated 23 March 2022 and attachments.

[2022] WACOR 29 be added to other information that is available on the signage. In my view, this is important information that people need to understand in order to properly assess the risks.

6 – Additional Shelter and Rest Stations along the trails

444. There appeared to be a general agreement amongst the witnesses from the various agencies that the Summit Trail could be improved by the installation of some sort of shaded rest stations along the path. Mr Snowball agreed that it would be “good to have a couple of little seats on the track to sit down”513 and was generally supportive of some sort of shaded structure, but indicated that of course the traditional owners will have to be consulted in relation to the details of any planned infrastructure projects.

445. Mr Snowball indicated he supports the introduction of more seating along the track to the summit, possibly even with some shelter, following appropriate consultation with the rangers and other traditional landowners. Mr Snowball also supports the concept of a memorial of some type being erected in memory of deaths that have occurred, which will inform other people of the real dangers that are present in the area.514

446. Mr Nicholson indicated at the inquest that DBCA has been considering what type of shelter might be devised for the trail since these tragic deaths, with the thought that if it was situated halfway up the Summit Trail, it might give people an opportunity to rest in shade and assess how they are feeling as well as perhaps providing a destination in itself for those unable to safely make it all the way to the summit but who could feel an achievement for making it halfway.515

447. Mr Nicholson gave evidence that DBCA are considering markers to indicate distance travelled along the trail, such as every kilometre, and also noting a halfway or even quarterway point, to give people a better guide for how far they have travelled and how far they have to go. This could assist walkers to assess their fitness to continue the journey. These changes are similar to what has been installed in Kalbarri.516

448. Mr Phillips gave evidence he had also had personal experience with the additional distance markers now installed at Kalbarri since November 2018, which mark every 500 metres of the trail and clearly show the distance hikers have travelled and how far they have left to hike of the 8km Loop Trail. Mr Phillips considers the additional markers to be very effective in helping people to gauge their ability to complete a walk. He noted that at Kalbarri on the Loop Trail, which is the trail that has been problematic in the Kalbarri National Park, there is a particular sign at the 5 kilometre mark asking people to consider “Are you okay?” with information explaining that heat kills and hikers have died along the trail. It indicates that it is an appropriate decision point as to whether they should turn back, because it gets harder from there.

513 Exhibit 3, Tab 10 [29].

514 T 10 – 11, 16, 19.

515 T 306.

516 T 306.

[2022] WACOR 29 There is also a small bench seat installed at the spot to create a destination point for those who are not able to complete the whole trail safely.517

449. I note that Mrs Buske told the police that after she and her husband had walked up to the summit they had both felt exhausted, tired and fatigued, but had believed that after a good rest stop they were sufficiently recuperated to get back to the car. She believes signs indicating how far to the summit along the walk would have been helpful to perhaps help measure that distance a bit better in terms of how they were feeling. Similarly, Mr Pollard indicated that Mrs Pollard had continued on when he stopped, as she believed it was only another kilometre to the summit, although she later told him it had been further than she thought. For them also, it was during the descent they then came into serious difficulty, as they were already hot and dehydrated before they even began their return.518 It does seem possible that a clearer halfway point with proper shelter and good markers and indicators of how much further was to go, might have helped Mr and Mrs Buske and Mrs Pollard to make a more well informed decision about whether they had the capacity to continue to the summit or not.

450. In terms of giving some information along the trail, probably at the halfway point, encouraging people to reflect on whether they can make it safely to the summit and back, Mr Phillips mentioned they are waiting for data on how many people in Kalbarri are turning back on the loop walk, which will give them some idea of whether that kind of information has the any effect.519

451. Acknowledging the information provided by DBCA about the steps being taken, there is no need for me to make any further comments or recommendation on this issue.

7 – Permanent and Clearer Markings for walk trails

452. Inspector Cox had raised concern at the inquest about the difficulty in seeing some of the markers that were used to mark the summit trail. Mrs Ansell gave her own personal account of having lost the trail on her return journey, as she could not see the marker. Inspector Cox was shown the new types of markers being installed on the trail, including markers on posts, prism markers and pole markers. Inspector Cox agreed the new trail markers were definitely an improvement, in particular the markers on posts and pole markers.520

453. Mrs Ansell, who had struggled to locate the small rock signs on the Edney SpringOombaroo Trail, was shown photographs of the new types of signage to be implemented at Mount Augustus, and she agreed they were a significant improvement in terms of visibility for walkers.521

454. BSS Jackamarra gave evidence that prior to the updates to the markers, she agreed that they were very puzzling and it was easy to lose your way and not find the 517 T 366 – 367; Exhibit 3, Tab 16, pp. 28 - 29.

518 Exhibit 2, Tab 1, pp. 21, 27 - 28.

519 T 383.

520 T 56 – 57; Exhibit 5.

521 T 95; Exhibit 5.

[2022] WACOR 29 markers set onto the rocks. BSS Jackamarra hasn’t seen the new signage, but has been told about what it entails, and she agrees it is a significant improvement.522

455. Dr Luckin suggested that the markers need to be fairly tall so that if people do inadvertently wander off the path, they can look around and see the top of the marker from a distance and navigate themselves back onto the trail. The trails should also have arrows pointing in the right direction so that if people are starting to become hyperthermic, dehydrated and confused, the know in which direction to head to return to the carpark. “well-marked, unambiguous trail, with markers that can be seen from a distance.”523 The new markers do seem to meet this criteria.524

456. If people do get lost, Dr Luckin recommends people should be told to stay where they are, rather than continuing to walk in a random direction, potentially getting even further off track. Dr Luckin noted that in many search and rescue operations around the nation, they find that people continue to walk around, which makes it much harder to find them.525 That is what Mrs Ansell admitted she did, although she believes her moving around eventually helped her to find the trail again, where she was found by Mr Snowball.

9 – St John’s Ambulance provide a first aid room at the Tourist Park and provide first aid training 11 – Suitable Emergency Management Equipment to be placed at the Tourist Park

457. Mr Hammarquist indicated that the station is registered to hold a RFDS medical kit.

The medical kit is in place more as a health and safety precaution for staff than with the aim to provide first aid for visitors. Mr Hammarquist explained that if someone requires medical treatment at the station, the staff will contact RFDS and speak with a medical practitioner over the phone, who provides advice as to what treatment to provide and what to use out of the kit. Visitors requiring first aid will generally be directed to the nursing post at Burringurrah, although the station first aid kit has been used for visitors on occasion.526

458. Mr Hammarquist was asked whether there was a defibrillator located at the Tourist Park, and he indicated that he did not think they had one on site. He believes the closest defibrillator is probably located at Burringurrah Community Nursing Post.527

459. However, information was provided by DBCA that, as a recent initiative, a selection of emergency first aid equipment is now located at the Tourist Park in a DBCA shed located onsite at the Tourist Park. This appears to have occurred after Mr Hammarquist left the area in September. The equipment comprises a defibrillator, an oxy viva resuscitation kit, a stretcher, emergency backpack style medical kit and some protective helmets for use in the event of a stretcher rescue. These items are available to the Tourist Park staff, if required. Mr Nicholson indicated that in the

522 T 204.

523 T 132.

524 Exhibit 5.

525 T 131 – 132.

526 T 270 – 271; Exhibit 3, Tab 11.

527 T 271.

[2022] WACOR 29 future DBCA is hoping to develop a little base at the Tourist Park for their staff to store tools as well as the emergency equipment, and he was also going to take steps to registering the defibrillator with SJA. Mr Phillips indicated in his report there had also been discussion about moving the emergency equipment items to the DBCA office in Burringurrah Community once the office is operational, although it is yet to be determined if this will occur. For my part, I would suggest that those items would be better placed at the Tourist Park, if they can be accommodated, given the closer proximity to Mount Augustus and also visitors staying at the Tourist Park who might become unwell, and noting that similar medical equipment is presumably already available at the Burringurrah Community Nursing Post.528

460. The station previously had a staff member trained in first aid, but there are no staff currently at the station/Tourist Park who are formally trained in first aid. Mr Hammarquist indicated he would be open to his staff receiving first aid training and he believes the staff would also be receptive to taking part, if the opportunity was there. Unfortunately, however, he noted that like most regional areas, the station is subject to staff turnover, so even if training is offered it may not mean that there will be suitably trained staff there at any given time.529

461. Mr Hammarquist indicated that in an emergency situation involving someone on Mount Augustus, the Tourist Park or station staff will contact the police and provide whatever information they have to hand. The police will advise the staff of a plan, which will differ depending upon the nature of the emergency. Staff at the station will assist with the plan where they can. Generally, they are told by police not to go onto Mount Augustus to look for a person, if they are reported missing. This is because the police are in charge of coordinating the emergency response, and neither Mr Hammarquist, nor any of his family or staff have been training in emergency management or medical emergencies. However, Mr Hammarquist’s son did provide information that he will generally still go out and start looking for any missing people, knowing that BSS Jackamarra has been notified and will be on her way to the area, but that she will take some time to get there.530 Having that emergency equipment and some first aid training, would obviously help them if they find someone who requires medical aid before anyone else arrives.

462. Mr Fonte, who gave evidence on behalf of SJA at the inquest, indicated that St John do have the capacity to deliver training to people to help them deliver first aid services in remote locations, and can provide advice on how to set up a properly equipped first aid station, but SJA wouldn’t fund those options.531 Mr Fonte gave the example of the Kalbarri National Park (which has come up quite a bit in this inquest as the gold standard), where SJA have put an unmanned defibrillator at the park in a lock box. It is currently the most remote publicly available defibrillator in the State.

If, as appears to be the case, a defibrillator is already available now at Mount Augustus via DBCA, Mr Fonte indicated that it could be registered with SJA so that if a person calls their call centre, they can be directed to it as the nearest defibrillator, and an operator can talk the person through the process of using it if required.532 528 T 283, 331; Exhibit 3, Tab 16, p. 53.

529 T 270 - 271.

530 Exhibit 3, Tab 20.

531 T 294 – 295.

532 T 294 – 297.

[2022] WACOR 29

463. There was some discussion about whether it might be advantageous to also have a defibrillator sited at Mount Augustus itself, as well as at the Tourist Park. Mr Fonte indicated that it is important, if possible, for the defibrillator to be located in a place where there is a cell phone signal, so that the operator can talk to the people attempting to use it and provide guidance. However, if communications were improved nearer to the hiking trails on Mount Augustus, it could be considered.533 Mr Fonte also gave evidence that following a spate of deaths in Kalbarri in similar circumstances, which led to the defibrillator being placed there amongst other changes, SJA has provided a set of guidelines to any ambulance crews who attend there to provide advice about where to find a cell signal and how to ensure the safety of staff while providing an emergency response. He noted that some of this information is also provided on signposts in Kalbarri, and noted that having those signposts up is a valuable tool that could be utilised at Mount Augustus in aa similar way, as well as having good information available to the SJA emergency operators.534 12 – Burringurrah Nursing Post staff to be trained and equipped to provide emergency assistance

464. This recommendation arose from issues experienced by the WA Police obtaining assistance at Mount Augustus from the nearest trained health practitioners, the nurses based at the Burringurrah Community Nursing Post.

465. Significant efforts were made during the search for Mr Buske to try to have some kind of nursing or medical assistance ready in the event he was found alive but in need of medical treatment. It became very clear that there was no ability to have a properly qualified medical standby response and it appears it would be left to the responders in the first instance to provide any medical treatment.535

466. It was noted that if he was found, RFDS would be at least 90 minutes away and there was no way of reducing that time. Although they had planes on standby and were ready to proceed with all haste and assist with recovery as well as treatment, they could only respond once the injured person was located.536 RFDS did provide advice that if Mr Buske was found alive, heat stroke or trauma were thought to be the most likely ailments. Immediate first aid steps for heat stroke, in terms of how to cool his body temperature, were provided by RFDS.537

467. In relation to SJA, theirs is a ‘best endeavours’ contract and it is clear that this does not generally encompass volunteers driving an ambulance from Meekatharra or elsewhere to Mount Augustus.538

468. Senior Sergeant Barwick’s attempts to arrange a doctor to attend the area to be on standby were unsuccessful and attempts to arrange a standby nurse who could

533 T 297 - 298.

534 T 298 – 299.

535 Exhibit 1, Tab 19, .p. 3.

536 Exhibit 1, Tab 19.

537 Exhibit 1, Tab 19, p. 15.

538 Exhibit 1, Tab 19, p. 3.

[2022] WACOR 29 provide treatment by way of a canula and intravenous saline bags extreme dehydration were also unsuccessful.539

469. Entry in the Incident Summary during the search for Mr Buske indicates a police officer spoke to a nurse at the Burringurrah Community Nursing Post. He had been advised by his Direct Line Manager that he could not leave the nursing post to assist at the scene under any circumstances. He was told he could assist if the patient was brought to him but was unable to assist in any other way. He had been directed that even in the event of a life or death emergency he was not permitted to leave the nursing post.540

470. Contact was then made with Mr Jeff Calver the WACHS Regional Manager as the Burringurrah Nurse is employed by WACHS. Mr Calver confirmed it is the policy for the nurse not to leave the post.

471. When Mr and Mrs Pollard were discovered, a different nurse who was working at the Burringurrah Community Nursing Post, Marie, was notified by police from the Burringurrah MFPF. She took it upon herself to ask her supervisors for approval to take the SJA van offsite to the scene to assist. Police tried to ring her back but had difficulty getting her as the line nursing post line went to health direct and they did not have her personal number.541

472. All of these issues were frustrating and concerning for the police involved. Inspector Cox made it clear at the inquest that his primary concern was that any nursing assistance needs to be able to provide early critical first aid, and in particular intravenous fluids for dehydrated patients, as this is likely to be required for anyone who is found still alive during a search and rescue operation at Mount Augustus.542

473. The general position of the WACHS is that the nursing post is not resourced to undertake an out of community emergency response. They have neither the staff, nor the appropriate vehicle to do so. The vehicle available to the nurses at Burringurrah Community is a patient transfer vehicle, not an ambulance, and the nurses are not trained for unplanned emergency care. That is generally the role of SJA, who is contracted to provide such services to all Western Australians throughout the State.

However, it was made very clear at the inquest that SJA is not in a position to provide any real emergency ambulance service to Mount Augustus in most circumstances. Therefore, the nurses at the nursing post are realistically the only people in the area who are able to provide anything akin to that kind of care in the event of an emergency.543

474. Superintendent Beer gave evidence that following Mr Buske’s death, when it became apparent that the Burringurrah Community Nursing Post staff were not being permitted to leave the nursing post and provide medical support at Mount Augustus, he had “some fairly robust discussion” with the Regional Director of WACHS. Since that time, Superintendent Beer understands the nurses have been supporting the 539 Exhibit 1, Tab 19, p. 5.

540 Exhibit 1, Tab 19, p. 4.

541 Exhibit 2, Tab 5.

542 T 46 - 47.

543 Exhibit 1, Tab 1, pp. 59 - 60

[2022] WACOR 29 emergency response, but he is unsure whether this is because of a change of policy, or because of his good relationship with the Regional Director or simply good local relationships with the nurses. Whatever the reason for the change, Superintendent Beer gave evidence he is satisfied that WACHS has certainly provided nursing support since Mr Buske’s death, when requested.544

475. Superintendent Beer clarified that he understood the initial reluctance was probably to do with the safety of nurses, rather than being deliberately obstructive. He now feels comfortable with the fact that the clinicians on site are very willing to help, and he has a good relationship with the Regional Director, so he’s confident they will get support when requested, wherever possible.545 Superintendent Beer noted that, given the very limited timeframe for survival on Mount Augustus, once they become aware the person is lost there is a relatively short critical time period when the medical services are required, before it is most likely changing to a recovery operation in any event.546 Therefore, some of the concerns about keeping nursing post staff away from the community for long periods is unlikely to occur.

476. Superintendent Beer also gave evidence that he has had many talks with SJA at a regional level, about the services provided in the Mid-West Gascoyne region, and it has been made clear that the regional contract is one of ‘best endeavours’, which means that they will come if they can. However, in places like Mount Augustus, which is a long way from the nearest service in Meekatharra, that often means that they can’t attend. Superintendent Beer gave evidence that he is aware of cases where two police officers have driven the ambulance in Meekatharra, because they can’t get two available volunteers, which makes providing any kind of ambulance service to Mount Augustus very, very problematic.547

477. Mr Hammarquist gave evidence that he has experienced issues with getting medical assistance from the Burringurrah Community Nursing Post staff often, not only for incidents on the summit trail but also other medical emergencies. In the past, he has been informed by the staff that they are not engaged to provide that kind of assistance and they were engaged only to provide medical services to the Burringurrah Aboriginal Community. In his role as Shire President, Mr Hammarquist met with management from the WACHS to try to resolve some of the issues, so that if there is a car crash or another incident, they can have some confidence that the Nursing Post staff might be in a position to assist. Mr Hammarquist gave evidence that he believes, like Superintendent Beer, that things have got a lot better in that regard more recently.548

478. Mr Patrick Green is the current Operations Manager for the WACHS in the Gascoyne region. Mr Green was not in the role at the time of these deaths, having come into the role about a year prior to the inquest. Mr Green spoke to the current health services provision in the Gascoyne region, in particular the Nursing Post at the Burringurrah Community. Mr Green explained that it is a two-nurse nursing post, with support staff such as cleaning staff generally employed from the local Burringurrah Community. The nurses are rostered to work five days a week and then

544 T 159.

545 T 159 – 160.

546 T 161.

547 T 160.

548 T 266.

[2022] WACOR 29 also work on rotation to be available 24/7 on call for emergencies. If the nursing staff are requested to leave the community to provide a health service, they conduct a risk assessment around what they are being asked to do and then the request is escalated up the line to an executive member or even the regional director, for approval or refusal, depending on the circumstances and the potential risks.549

479. Mr Green explained that there is a standardised risk assessment form used for this purpose, as the same process across the WACHS health services. One main focus will be on where they are actually headed to, as well as the skill set of the staff and what other support services might be available.550

480. Mr Green was asked if he knew why the police request for assistance in November 2019 in relation to the search of Mr Buske was refused. Although he was not in the role at the time, Mr Green had made enquiries and understood that the request was denied based on the fact that, as it was still at the search stage, there was no certainty about timeframes, durations, what the nursing staff were actually going to be doing and whether they might be required to go up Mount Augustus, which is not what they are employed to do. Mr Patrick suggested if he was in a similar situation, he would have been seeking more information before making a decision, but he considers that based on the information that was available at the time, the decision was reasonable.551

481. Mr Green indicated that it is an ongoing issue, as there are many requests from police for nurses to attend incidents in the regions, which is understandable given the limited ambulance services. WACHS tries to work with the local police and emergency services, preferably with a conversation at a high level between the Officers-in-Charge of stations and the Operations Managers of the hospitals or nursing posts concerned, to try and ascertain as much information as possible and reach a resolution. However, they need to ensure that they are not putting health staff at significant risk.552

482. Mr Patrick indicated that there is no Memorandum of Understanding between the police and the Burringurrah Community Nursing Post staff in relation to incidents at Mount Augustus and there has been no change to the relevant policy that applies.

However, there is, perhaps a better understanding between the local police and the WACHS staff about how the requests will be managed. Each incident continues to be dealt with on a case by case basis, but there is now an executive-on-call system throughout WACHS that has perhaps improved knowledge of how to respond and what considerations are to be taken into account when making these decisions.553

483. Mr Green indicated the WACHS is part of the local emergency management committee meetings, which police also attend, and they are able to discuss emergency responses more generally at those meetings, to canvas any concerns and continue to forge relationships. There are also ongoing meetings with the local SJA team, but Mr Patrick conceded that there is not always an ambulance service able to attend Mount Augustus from Meekatharra. However, Mr Patrick was able to indicate

549 T 242.

550 T 243.

551 T 243 - 244.

552 T 244.

553 T 244, 248 – 250.

[2022] WACOR 29 that there have been occasions, such as a motor vehicle rollover at the Burringurrah Community, where that ambulance service has been able to assist.554

484. Mr Patrick indicated there is a patient transfer vehicle currently at Burringurrah Community, but it is still not an ambulance as it doesn’t have full oxygen and other medical equipment plumbed. The patient transfer vehicle only has very minimal medical equipment on board, such as a stretcher and portable-based medical equipment that can be taken from the clinic in the event of an external emergency.

Importantly, the vehicle is not equipped for the provision of intravenous fluids, but at the nursing posts there are remote first-aid kits, known as PARI packs, which do include 4 x 500 ml saline IV drip bags, as well as two IV giving sets, so there is capability to provide that IV fluid on site at the nursing post. Mr Patrick also confirmed that the remote area nurses are trained to provide that treatment. However, he also explained that not all of the staff at the nursing post are qualified remote area nurses, as it is not always possible to recruit and retain them. Therefore, sometimes there may be a registered nurse at the nursing post, who does not have that additional remote nursing training, which includes being trained to put IV’s in. However, Mr Patrick indicated that they usually aim to ensure at least one of the nurses at Burringurrah Community is a trained remote area nurse at any given time.555

485. So in summary, the current position is that there is a general understanding between the WA Police and WACHS, that Burringurrah Community nurses can be asked to attend Mount Augustus to provide assistance with an emergency response, and the nurses will then seek permission from their line management. WACHS staff will support the requests, where possible, provided it is safe and practical for the nurses to do so. However, Mr Patrick also emphasised that, the health system in WA is stretched at the moment and staffing in remote areas is particularly hard, so it is not guaranteed that staff with the appropriate remote area qualifications, and experience will be there at any given time. The response, therefore, is dependent on resourcing and the particular staff available, as well as the risk assessment.556 13 – Mount Augustus Airstrip to be upgraded to allow RFDS to land at night

486. The Mount Augustus station has an airstrip with a dirt/gravel runway located to the north east of Mount Augustus. The airstrip is owned and managed by the station. Mr Hammarquist indicated the airstrip is serviceable and has been used by RFDS in the past. It has also been used by tourists. The airstrip has no lighting so it generally cannot be used at night, although Mr Hammarquist indicated in his statement that in the past they have used flares and vehicles to illuminate the airstrip in an emergency situation. There are also issues with the airstrip during the wet season, as it can go under water at times, which can make it inaccessible for short periods of time. While Mr Hammarquist gave evidence that he still thinks the airstrip is generally a good airstrip, he accepted that with the increase in visitors to the area, the community would benefit from a newer airstrip in a different location.557

554 T 245.

555 T 246 - 247.

556 T 247 – 250.

557 T 266; Exhibit 3, Tab 11.

[2022] WACOR 29

487. Other than the Mount Augustus station airstrip, currently the next nearest airstrip is at the Burringurrah Community.

488. The RFDS provided information to the Court that the Mount Augustus airstrip is categorised as a hazardous airstrip and night landings are not permitted. Any flights to Mount Augustus need the authorisation of the RFDS chief pilot to proceed, which does create difficulties in responding to medical emergencies there. The Burringurrah airstrip is utilised more frequently, as it is a better airstrip, but it is approximately 100 km away from Mount Augustus by gravel road.558

489. Mr McCleary, the local Shire’s CEO, agreed in his evidence that the Mount Augustus area is “really crying out for .. an airstrip to go in there so the RFDS can land … from an emergency point of view.”559 Both Mr McCleary and Mr Hammarquist indicated that a new airstrip is one of the projects that the steering committee is hoping to fund with the $10 million budget allocation from the government. However, Mr McCleary explained that there needs to be consultation with the local Wajarri community, who have been granted native title over the relevant area, in order to negotiate a joint land use agreement. He understands this consultation is being undertaken by DBCA, but has not progressed very far at this stage. Once agreement has been reached, then the steering committee can progress to considering issues such as costing and design, solar power initiatives and the like.560

490. Mr McCleary did express some frustration at the inquest about the limited availability of the RFDS to attend incidents, in any event, even with an improved airstrip, which to a certain extent leads into the next recommendation.561 14 – Investigate the viability of a rescue helicopter based in the mid-west with capability to remove critically ill patients off Mount Augustus.

491. Inspector Cox explained that with this recommendation, he was proposing something similar to the RAC helicopters that are currently based in Perth and Bunbury. If such a service was based in the Gascoyne, Inspector Cox noted it could also be utilised for other rescue services required in the Mid-West and along the Indian Ocean Road.562

492. Inspector Cox explained that for Mount Augustus in particular, the benefit would be that a rescue helicopter would have the capability to winch an injured or ill person off the trail, rather than having to carry them down on a stretcher to safety. It would enable first aid to be provided much more quickly to the person requiring it, and avoid the necessity of multiple people having to be involved in a stretcher rescue.563

493. Superintendent Beer gave evidence that, due to the base locations of the current WA rescue helicopters in Perth and Bunbury, they are very rarely deployed north of Jurien Bay, so they do not have access to a rescue helicopter in the Mid-West 558 Exhibit 3, Tab 12.

559 T 219.

560 T 219 – 220, 267.

561 T 221 – 222.

562 T 60.

563 T 60.

[2022] WACOR 29 Gascoyne region to any significant degree. That means the helicopters they do utilise are purely for search purposes, and not rescue.564

494. The resources at the Police Airwing are not an option as a replacement for a rescue helicopter. It takes the two Polair helicopters between 3.5 to 4 hours (including fuel stops) one way from Jandakot to Mount Augustus and the helicopters do not have the capability to winch people to safety, in any event.565 Police Airwing assists in other ways, bringing resources to the area.

495. Mr Wilson, who is the District Officer for DFES in Geraldton, was not certain of the Departmental position on a rescue helicopter in the region, but believed that the establishment of a rescue helicopter would be of benefit to the broader local community, not only for Mount Augustus , as it would enable a more rapid response to be provided in emergencies. Mr Wilson gave the example of delivering medical, food and water supplies to people stranded by floods, which are common in the region, as well as medical evacuations in remote areas or for urgent medical situations.566

496. Acting Assistant Commissioner Paul Carr from DFES also gave evidence at the inquest to explain further the role that DFES plays in these operations. A/Ass Commissioner Carr performs the role of looking after country operations for DFESrelated hazards, which includes fires, floods, cyclones and storms, and the capability of DFES to raise and main volunteer services to respond to those hazards. A/Ass Commissioner Carr gave evidence that DFES have supported three submissions for government funding for a rescue helicopter in the Mid-West Gascoyne region, but to date none of them have been funded. The type of helicopter sought would be an aeromedical helicopter with a paramedic on staff and winching capabilities. Like the other two RAC-sponsored helicopters. A/Ass Commissioner Carr acknowledged that the funding for such a service is substantial, running into the millions of dollars, but noted that the current rescue helicopters in Perth and the south-west are based too far away to provide any kind of support as you head north in the State. The funding submissions have sought to have another rescue helicopter based in Geraldton to service the Mid-West Gascoyne, including Carnarvon and Geraldton and all the way through the region. It would obviously play a role in search and rescue missions on Mount Augustus, particularly if had winching capabilities, but could also be utilised for motor vehicle accidents, and other medical support that would generally be provided by SJA or WACHS in less remote areas.567

497. I acknowledge that there is a considerable cost involved in establishing and running another rescue helicopter in this State. However, there is a demonstrated need for such a service, particularly when consideration is given to the lack of any meaningful ambulance service to large parts of this huge area. It would have been a very useful resource in the case of these deaths, potentially both to assist the emergency responders in trying to locate the missing persons as well as to retrieve their bodies.

As Inspector Cox noted in his report, it would also be a significant safety precaution to have in place when putting SES and police personnel in the extreme conditions at

564 T 161.

565 Exhibit 3, Tab 1.

566 T 176 - 178.

567 T 182 – 183.

[2022] WACOR 29 Mount Augustus, which puts their own lives at risk while looking for someone else who is already in danger.568

498. I have read the response from the then Minister for Emergency Services, the Hon Francis Logan MLA, to the Chair of the Standing Committee on Environment and Public Affairs regarding Petition No 155 – Midwest region-based Rescue Helicopter Service. The correspondence was dated 17 September 2020, so coincidentally only a few days after the deaths of Mrs Pollard and Mr and Mrs Green. The letter indicated that the State Government is committed to enhancing emergency services capability and that any expansion of the Emergency Rescue Helicopter Service would be considered as a part of the Government’s commitment to long-term planning in emergency services. It was noted that the two rescue helicopters operational at that time were operating within 250 km from their respective bases, which covers approximately 90% of the State’s population. The Minister acknowledged the existence of an election promise of $30 million from Royalties for Regions funding to establish a Midwest Emergency Rescue Helicopter Service based at Geraldton, but suggested that the funding only addressed short term capital funding and not recurrent operational funding for the service. It was noted at that time that there was consideration being given to the next generation of helicopters, which might have greater capabilities.569

499. I note that on 15 December 2021 the Emergency Services Minister, the Hon Reece Whitby MLA at that time, announced that the McGowan government would be investing more than $50 million for three new rescue helicopters. The helicopters will have an increased range from their bases at Bunbury and Jandakot airports, but it is not clear if it will reach the Mid-West without the need to refuel. The additional third aircraft is also not to add a rescue helicopter to a new base, but rather to act as a back-up for the two primary rescue helicopters. However, it is mentioned in the media release that the third aircraft will be able to be mobilised to support other emergency services incidents, with examples given of the Carnarvon floods and Cyclone Seroja. The rescue helicopters are all fitted with rescue winches and night vision imaging systems and it is mentioned that they can respond to incidents any time day or night and in very remote or inaccessible parts of the State. Whether or not that extends to Mount Augustus is unclear.570

500. In my view, it is appropriate and fair that the Western Australians living in the MidWest of Western Australia and above be provided with air assets to assist with search and rescues, in the same way that those of us living in Perth and the South West are lucky enough to have access to, noting we also have access to a far more comprehensive ambulance service on the ground. It is unclear from the information available how available the additional rescue helicopter will be to people in the MidWest. If is not readily available, then that is of great concern, particularly given the abovementioned election commitment to ensure that such a service is made available to people in the Mid-West.

568 Exhibit 1, Tab 1, p. 76.

569 https://www.parliament.wa.gov.au/Parliament/petitionsdb.nsf. – ev.155.200924.let.001.fl.

570 https:///www.mediastatements.wa.gov.au/Next generation rescue helicopters to take to the skies, Wednesday, 15 December 2021.

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501. Given the uncertainty around this issue, it is difficult for me to make a recommendation. I also note that the need, and community support from those in the regions, for this service has been made very clear to the current government in recent years and has been considered by the relevant Minister. Therefore, I do not propose to make a recommendation in relation to investigating the viability of a rescue helicopter based in the Mid-West as it has already been done recently and apparently rejected. All I can do at this stage is comment that I hope that the State Government has taken into account the needs of the people of the Mid-West and the many risks involved in the region, including people who come into difficulty at Mount Augustus, in making that decision.

15 – Burringurrah MFPS to be manned at all times to provide an emergency response

502. Superintendent Beer gave evidence that this recommendation was taken on board by WA Police and two police officers are now permanently stationed at Burringurrah Community, and replacement staff are sent there when the permanent staff have to leave for training, court commitments or leave.571 Accordingly, there is nothing more that needs to be considered in relation to this proposed recommendation.

CONCLUSION

503. As Inspector Cox noted at the end of his comprehensive report, these recent deaths at Mount Augustus are a reminder of the dangers of hiking in remote Western Australia in extreme heat. There are limited resources and communication capabilities in these remote areas in the event of a medical emergency or a search and rescue operation, which hampers the emergency response. People need to understand that if they get into trouble, help may not arrive soon. Therefore, the emphasis needs to be on prevention, particularly until the State Government commits to improving rescue and ambulance services in these areas

504. Inspector Cox observed that ultimately, the responsibility for the decision as to whether a person is capable of hiking to the summit rests on the individual. If people think carefully about their abilities, and walk within their physical capabilities and take the necessary precautions, further unnecessary deaths can be prevented.

However, Inspector Cox firmly believes that there also needs to be larger structural changes made, to help people make the right decisions.

505. This inquest addressed the sudden and unexpected deaths of Mr Buske, Mrs Pollard and Mr and Mrs Green. The evidence before me indicates that all four deaths were consistent with dehydration and hyperthermia. All of the deceased were sensible, mature people and experienced travellers who were not the kind of people who would willingly engage in risky behaviour. What they all had in common is that they all had insufficient warning before they did the walk of the risks that they faced and the steps that they should take if they wished to attempt the Summit Walk at that time of year. Mr Buske was certainly not acclimatised to the hot weather, and it is difficult to tell how well the other three people were acclimatised, having come from Perth in Spring. All of them had other risk factors that were likely to make the walk

571 T 60, 152 - 153.

[2022] WACOR 29 more arduous for them and leave them exposed to the heat in the middle of the day, but it seems they were unaware this was the case until it was too late.572

506. While we are focussing on these four deaths, and paying some heed to the earlier deaths and Mrs Ansell and Mr Pollard’s near misses, I note that Dr Luckin also gave evidence he has no doubt a considerable number of people complete the walk severely dehydrated and overheated and having sailed fairly close to the wind. They then go away without realising how close they came to serious harm or death. Dr Luckin noted that some people will have sustained kidney damage and will suffer diminished kidney function without even realising the cause. Therefore, just because some people have managed to complete the walk with less water than recommended, or not following Dr Luckin’s safety recommendations in other ways, does not mean they necessarily have escaped unscathed, and it is possible they unknowingly came very close to becoming a statistic themselves.573 This was confirmed by the local police sergeant, who has seen many people who have managed to make the descent, but arrived back in a distressed state.574 This is relevant as it supports the conclusion the four deceased the subject of this inquest are not outliers in terms of their behaviour on the hike, and the same fate could happen to anyone.

507. The cost of mounting an emergency response was also mentioned at this inquest.

Inspector Cox estimated the search for Mrs Ansell, who went missing and was found, was in the vicinity of $80,000, even though it took place over a relatively brief period. The cost of a longer search can be in the vicinity of $100,000 per day. These figures are raised not to suggest that any price limit can be put on the need to search for people in trouble, but rather to indicate that the high costs of mounting this type of search mission might be better spent on making the kinds of structural changes suggested, in order to prevent the need for the searches to occur, or at least limit their size and duration.575 Death prevention is a much better way to spend government resources than on a search and rescue mission that may or may not save a life.

508. In terms of that death prevention, a topic of discussion during the inquest was the possibility of establishing some kind of permanent memorial at the base of the Summit Trail, to commemorate these deaths (and perhaps the others I have mentioned), both as a recognition of the lost lives and as a warning to others of the real risks involved in hiking in this unforgiving environment. The traditional owners are supportive of this as a concept and I was informed that the traditional owners would also like to be involved in a ceremony relating to the memorial (if it is erected) in order to provide closure to the deceased’s loved ones. DBCA have indicated their support for the concept, after appropriate consultation with the families of the deceased and the traditional owners to ensure that any such memorial is respectful to all.576 Some of the family members have already expressed support for the idea and Mrs Buske’s counsel indicated that the German Government would like to be involved in funding any memorial to Mr Buske at the site, so hopefully this idea can be progressed.

572 T 126.

573 T 126 – 127.

574 T 203.

575 T 30.

576 T 355; Submissions filed on behalf of DBCA, WA Police, DFES and WACHS dated 17 December 2021.

[2022] WACOR 29

509. I encourage DBCA to take ownership of the memorial proposal and consult with the relevant parties to see if something meaningful can be erected that will honour the memories of those who have died on the trail, and also serve as a reminder to other visitors that they need to ensure that they prioritise their safety and follow all of the warnings that will hopefully soon be in place. The hope is that all of these changes will ensure that future visitors will be able to return to their families at the end of what will hopefully be a wonderful experience in a beautiful and sacred part of the world.

S H Linton Deputy State Coroner 17 June 2022