Record of Investigation into Death (Without Inquest)
Coroners Act 1995
Coroners Rules 2006
Rule 11
These findings have been partially de-identified in relation to the name of deceased and friends by direction of the Coroner pursuant to S.57(1)(c) of Coroners Act 1995
I, Stephen Raymond Carey, Coroner, having investigated a death of
'Master B'
WITHOUT HOLDING AN INQUEST
FIND That:
a) The deceased is 'Master B' who died on 18 August 2012.
b) 'Master B' was born in Hobart in December 1998 and was aged 13 at the time of his death.
c) 'Master B' was a student.
d) 'Master B' died as a result of multiple blunt traumatic injuries sustained when the bicycle he was riding impacted with a motor vehicle.
Circumstances Surrounding the Death:
'Master B' resided with his parents and siblings at the family home at Glenorchy. He attended New Town High School and was in Grade 8. On the evening of Friday 17 August 2012 a friend of 'Master B', spent the night at 'Master B's' home. On the morning of 18 August 2012 'Master B' and his friend left the Clydesdale Avenue residence sometime around 11.30am. Both boys were riding their bicycles. Neither 'Master B' or his friend were wearing bicycle helmets. It was the intention of the boys to ride to one of their friends home located in Berriedale.
'Master B' and his friend rode their bicycles to the skate park in Abbotsfield Road, Claremont. At the park they met up with another school friend. Their friend was riding his bicycle in the park and he was wearing a bicycle helmet. Whilst riding in the skate park 'Master B' has fallen off his bike and this resulted in him suffering a small graze to his right arm just above the elbow. He didn’t complain of any other injury. The handle bars, front wheel and forks on 'Master B’s' bike were out of alignment due to this fall. One of his friends straightened the handle bars but they still required tightening so the boys agreed to ride to one of their houses in Berriedale so that repairs could be carried out on the bicycle. Prior to leaving the skate park 'Master B' indicated to his friends that the brake levers on his handle bars were tight and hard to operate. The boys left the skate park at approximately 1.22pm.
The boys have ridden their bicycles to Boxhill Road, Claremont. In the vicinity of the junction of Rosbar Street the boys have stopped and had a conversation. Boxhill Road at this location has an east/west orientation, there is a crest in the road with a significant down slope of 8% towards the east. When the boys stopped on this occasion 'Master B' indicated that his bicycle did not have brakes. Both his friends advised 'Master B' to walk down the hill and not to ride because it was steep and he didn’t have operating brakes on his bike nor was he wearing a helmet. Both his friends commenced riding down the footpath on the southern side of Boxhill Road and they observed 'Master B' walking his bicycle down the hill. However 'Master B' has then got onto his bike and commenced riding it down Boxhill Road towards the junction of Main Road. As he has approached the junction with Main Road he has attempted to slow the bicycle down by placing his foot on the ground. As he approached the intersection of Main Road and Boxhill Road which is controlled by traffic control lights, the lights facing 'Master B' were showing red. 'Master B' has been unable to stop and has proceeded through the red light and has attempted to steer his bike to the left, or northerly direction, along Main Road. However he has been unable to make that turn or alternatively has lost control of his bicycle and has impacted into the side of a white Ford utility driven by 'Mr M'.
'Master B' has come to rest on Main Road in the southern bound right hand turning lane and the utility has stopped in the first available parking space on the southern side of the intersection. 'Master B' was attended by members of the public, however CPR was not commenced but was when ambulance personnel arrived. However after a short time this was discontinued as there was no cardiac output and 'Master B' had obviously suffered significant head trauma.
An extensive investigation has been conducted by Tasmania Police in relation to this accident. I am satisfied based upon the results of that investigation that neither weather nor road conditions contributed to the accident. I am also satisfied that the driver of the motor vehicle involved, 'Mr M' was in no way at fault. His motor vehicle was noted to be a well maintained and roadworthy vehicle, 'Mr M' was proceeding through a green light and was travelling below the applicable speed limit. There is a building on the north-western corner of the intersection and the façade of that building restricts sight distance for drivers of vehicles approaching the intersection from the west (on Boxhill Road) and also from the north (on Main Road). The investigation determined that a driver of a south-bound vehicle on Main Road has to be within 15 metres of the commencement of the intersection with Boxhill Road before there is any significant sight distance of vehicles and bicycles approaching the intersection from the west on Boxhill Road. 'Master B' therefore has not been visible to 'Mr M' until he has ridden passed the façade of that building and from that point he has ridden a distance of 11 metres to impact. Given these findings 'Mr M' has had insufficient perception and reaction time to take any form of effective evasive action.
Examination of 'Master B’s' bike indicated that it did not have a fully operational and functional braking system, in particular the rear brake friction material was misaligned. There was also an indication that some other aspect of the braking system was not working correctly given the observations made by 'Master B' that he did not have effective brakes on his bike prior to riding down Boxhill Road on what was described as a relatively steep incline. It is clear from witness observations that 'Master B' has attempted to slow his bicycle by using his foot on the ground, has failed to do so and has been unable to manoeuvre his bicycle so as to avoid impact with a motor vehicle.
Comments and Recommendations:
This tragic accident highlights two matters in respect of the use of bicycles. Firstly, it provides a stark example of why helmets must be worn by those riding bicycles. Those who have the care and responsibility of children must ensure they wear a helmet. Secondly, there is a clear responsibility for those operating a bicycle or those having the care and responsibility of children to ensure that bicycles they are riding are at all times in a proper mechanical condition so as not to expose the rider to the risk of accident and injury. In particular, the braking system of bicycles must at all times be properly fitted and adjusted so as to be capable of bringing the bicycle to a halt in a controlled and effective manner.
Before I conclude i wish to convey my sincere condolences to 'Master B's' family.
DATED 25 day of March 2013 at Hobart in the state of Tasmania
Stephen Raymond Carey
CORONER