RECORD OF INVESTIGATION INTO DEATH (WITHOUT INQUEST)
Coroners Act 1995
Coroners Rules 2006
These findings have been de-identified by direction of the Coroner pursuant to S.57(1)(c) of the Coroners Act 1995
I, Reg Marron, Coroner, having investigated the death of the deceased have decided not to hold an inquest into the death because the investigations into the death have sufficiently disclosed the identity of the deceased person, the time, place, cause of death, relevant circumstances concerning the death, and the particulars needed to register the death under the Births, Deaths and Marriages Registration Act 1999.
I do not consider that the holding of an inquest would elicit any information further to that disclosed by the investigations conducted.
I find that :
(a) The identity of the deceased is Mr. H who was born in Burnie, July 1966.
(b) The deceased died on 30th December 2011 at Union Bridge Road, Paradise, Tasmania.
(c) Mr H. died as a result of injuries sustained when his motor cycle slid into the path of an oncoming car in the opposite lane.
(d) The cause of his death was multiple trauma consistent with a motor cycle accident.
Circumstances Surrounding the Death :
The deceased was married and the couple lived in Northern Tasmania. His wife that her husband had been riding motorcycles since the age of 16 years and that it was his usual form of transport and he rode regularly. He had undertaken Stay Upright Motorcycle Courses, would participate in track days and he was involved in Riders of Tasmania Forum. He was heavily involved in motorcycling. The deceased had purchased the motorcycle a Honda CBR 1000 RR in about 2006 or 2007. He was fastidious with his bike maintenance, was extremely proud of his motorcycle and looked after it very well.
On the morning of 30th December 2011, the deceased set out from his house to drive to Sheffield to meet up with some other riders who were planning on driving to Hobart via the East Coast that day. Mrs H said that her husband also planned to ride to his sister's place. When he left he was wearing his leathers, he had earplugs in and he had his glasses and helmet on. When he left he was in a happy state of mind.
Mr Brian Hughes, the manager of Shearwater Motorcycles stated that the deceased had come into his store at about 8.15am on Friday, 30th December 2011 and asked him to remove a metal fragment from the rear tyre. The deceased indicated to Mr Hughes that he was heading to the east coast. When he left he appeared to be in a good frame of mind. Mr Hughes had known the deceased for about six years and regarded him as a capable rider and that he was fairly fastidious with regard to the maintenance of his motorcycle.
At about 9.28 a.m, the deceased rang his wife from Sheffield to say he had missed the riders he was travelling with as they had left early. He said he wouldn't be able to catch up with them and he wasn't sure what to do. His wife was not sure what her husband was intending but believed that he would have a ride and then decide what to do. He had told her that he would let her know later in the day what he was doing.
On that morning, Mr. J was driving his Holden Rodeo 2001 four-wheel-drive turbocharged diesel dual cab on Union Bridge Road. He had earlier left home in West Kentish at around 8:25am and travelled to Mole Creek for an induction for work at the Mole Creek Lime Works finishing at approximately 9:30am. He then left to drive home. He said he was not in a hurry. He was driving up a steep hill that was quite narrow and he estimates he would have been in third gear. He was on a straight section of road about to enter a right-hand bend. He saw a motorcycle coming from the opposite direction and noted that the rider instantly turned the handlebars onto a hard left lock which caused the front wheel to start sledging. Mr J did not see any braking by the rider. It was his opinion that if he had not come a long that the motorcyclist would have run straight off the bank as he did not appear to be taking the corner at all.
Once the bikes handlebars were turned, Mr J said the bike almost went down on the road and he saw sparks and the brake lever snap off. He heard the bike revving loudly and then lost sight of the rider. Mr J estimates that it was about three seconds at most from when he first saw the motorcycle to hitting it with his car.
Mr J was uninjured. He stopped his car, got out and tried to call triple 000 however the phone reception was poor. About 10 to 15 seconds later he said he heard a car coming and flagged it down. That car was driven by Mr C who stopped and used his two way radio to call for help. They then put the rider into recovery position and Mr C checked for a pulse but didn't find one. Mr C recognised the motorcycle as being the one that had overtaken him a couple of minutes earlier. Another car pulled up and that driver also checked for a pulse and finding none told the others that the motorcyclist was dead.
Mr J, a truck driver by profession all his life, was of the opinion that the motorcycle was not in a normal position to take the corner in a manner which Mr J would have expected him to be riding in. Mr J with whom Mr C agreed, noted that at the time of the crash, the road was dry, it was fine and warm, the weather was perfect and there were no distractions on the road at all. There was very little traffic flow on the road.
Inspection of the vehicles:
The motorcycle driven by the deceased and the utility driven by Bruce were both examined by, a transport inspector with the Department of Infrastructure Energy and Resources in Burnie. The inspector found that the motorcycle had sustained extensive damage both to the front and front right-hand side. It was his opinion that prior to and at the time of impact, the motorcycle as inspected would have been classed as being mechanically sound and roadworthy and that all damage was consistent with crash damage.
He further found that the utility had damage concentrated the right side of the front bumper bar and sump guard. The front bumper bar was pushed rearward. The front body cross member and air-conditioning condenser was impacted rearward and the driver's side front indicator body was broken and the lens was cracked. It was his opinion that all this damage was consistent with crash damage. He also noted that the vehicle would have been classed as unroadworthy due to a rear brake imbalance being 9.5% more than allowed to pass a roadworthy and that it had in operative passenger indicator. It was possible however, that the front passenger indicator lamp may have failed as result of impact. His inspection did not reveal any fault could have caused the collision.
I/C Constable Adam Lloyd, a trained crash investigator, attended and examined the scene. He observed the road surrounding the crash scene was a country road in a rural area. It was in relatively good condition and did not have any line markings. The speed limit at that point was 100 km/h. He observed the Holden Rodeo utility on the far western verge of the roadway on the edge of a very steep precipice into a galley. He observed a scalloped type tyre mark which he attributed to the tyre of the motorcycle sliding sideways down the road. The tyre marks commenced over the centre of the road and was well outside a normal line the motorcycle would have taken through the left hand corner that the deceased's motorcycle was navigating. There was no visible sign of evasive action from the motorcycle. He observed marks on the road which he attributed to the deceased sliding down the road. These marks led him to the conclusion that the deceased had fallen from the motorcycle and onto the road surface well prior to the motorcycle colliding with the Holden Rodeo utility. The marks were also consistent with the deceased having not collided with the Holden Rodeo utility but having slid down the road to the rear of the utility.
On 3rd January 2012, a post-mortem examination was conducted by Dr Terry Brain at the Launceston General Hospital. Dr Brain identified a number of significant injuries. He noted the cause of death was multiple trauma consistent with a motorcycle accident. The toxicology report revealed the presence of Warfarin in the sub therapeutic quantities but was otherwise unremarkable.
Past medical history:
Dr L from the Port Sorell Medical Centre, reported that the deceased had fallen off his motorbike on two previous occasions.
" In 1998 he ran off the road and crashed his motorcycle, he needed resuscitation and intensive care treatment for fractured ribs.
In 2008 he crashed his motorcycle for no good reason and fractured his wrist.
He was investigated by Consultant Cardiologist Dr S who found he had a heart irregularity and after treatment advised him in 2009 to refrain from driving motorcycles for life or at least 12 years in interest of his own safety".
Of these two crashes, Dr S reported that the deceased had in relation to the first in 1998:
"ran off the road, maybe have felt light headed temporarily, according to his wife. He was resuscitated, including cardiac massage and mouth-to-mouth ventilation. He had severe injury, necessitating hospitalisation in intensive care and ventilation.".
And of the second crash in 2008, that the deceased had:
"ran off the road, there are no preceding symptoms. Trauma resulting in fracture right radius and older and sternal fracture"
Dr S also recorded that the deceased had two other medical incidents;
2003 "an episode of paroxysmal atrial fibrillation"
June 2007 " a left bundle branch block"
In his report to Dr L in late December 2008, Dr S concluded,
"this is a difficult issue. He had two major accidents during which he ran off the road with significant injuries. There are no clues as to the cause of his two episodes. It is possible he had paroxysmal atrial fibrillation, rather rapid leading to lightheadedness. He certainly has non-ischaemic dilated cardiomyopathy, left ventricle injection fraction 40%, one can't quite rule out ventricular arrhythmia, though during recent hospitalisation for a few days, telemetry did not reveal any abnormalities"
After noting the results of clinical investigations carried out and a diagnosis of dilated cardiomyopathy, Dr S concluded:
"two episodes of unexplained running off the road with major injuries, can't be taken lightly, one cannot rule out arrhythmia leading to syncope and in keeping with Commonwealth guidelines he should not be allowed to drive for six months". (Emphasis added)
Mrs H says that her husband followed this instruction and did not drive for six months after the initial appointment with Dr S in December 2008.
Dr S prescribed and monitored Mr H medications and carried out further investigations. In February 2009, Dr S again reported to Dr L and confirmed a diagnosis of "non-ischaemic dilated cardiomyopathy probably familial cardiomyopathy". The physiological cause of two episodes of running off the road was unclear He reported that overall that there was a considerable improvement in the deceased's cardiac function (heart monitoring did not show any rhythm abnormalities whatsoever).
Dr S predicted that given six months he would think that Mr H's cardiac function would normalise. As there was no clear evidence of atrial fibrillation and the deceased's heart function had improved, he felt it would be possible to withdraw the warfarin medication in six months time. He proposed further heart monitoring in a month and said that " if that was negative that Mr H could be allowed to drive a motor vehicle, however not a motorised bike." (Emphasis added)
In his final report in April 2009, the Dr S reported confirm that heart monitoring showed no abnormalities whatsoever. Dr S said that he thought that the deceased should be able to drive a motor vehicle but refrain from driving motorcycles perhaps for life, at least for the next 12 years in the interest of his own safety. (Emphasis added)
Dr L further reported that; " Unfortunately Mr H while aware of Dr S's advice not to drive, could not follow that advice of Dr S", which advice Dr. L reinforced with the deceased at least once in 2010.
Dr L had last seen the deceased on 7th December 2011 when his warfarin level was checked, and found to be within the normal range. He has been seeing Dr L regularly throughout the year, he took his medications regularly for his heart. His blood pressure and heart rhythm were normal and he appeared to Dr L to be in good health.
It was Dr L's opinion that his heart condition could have caused his death when he fell off his motorcycle on 30th December 2011.
Duty to report
The provision for a licence holder to notify the Registrar about a change to a medical condition is set out in regulation 36(6) of the Vehicle and Traffic (Driver Licensing and Vehicle Registration) Regulations -
The holder of a driver licence must, as soon as practicable, notify the Registrar of -
(a) any permanent or long-term injury or illness that may impair his or her ability to drive safely; or
(b) any deterioration of physical or mental condition (including a deterioration of eyesight) that may impair his or her ability to drive safely; or
(c) any other factor related to physical or mental health that may impair his or her ability to drive safely.
Enquiries made of the Department of Infrastructure Energy and Resources Land Transportation Safety Division, reveal that at no time did the deceased notify the Registrar of Dr S's diagnosis and his opinion in December 2008 that the deceased should not be allowed to drive for six months, or his opinion in April 2009 that the deceased refrain from driving motorcycles perhaps for life, or at least for the next 12 years.
Comments & Recommendations
From the medical information provided by Dr S and Dr L and from the information provided by Mr J, I am of the opinion that it is likely that the deceased's medical state affected his ability to properly control his motor cycle at the time causing the bike to fall and slide into the path of Mr. J's Holden Rodeo utility.
At that time the deceased crashed his motorcycle into Mr J's utility, he was driving against the medical advice of his specialist Dr S and his GP Dr L. He was aware of this advice. Despite this, the deceased chose not to reveal any of this information to the Registrar of motor vehicles.
It appears that Dr L was aware that the deceased was choosing to ignore the medical advice given to him and that he was continuing to drive against this advice. The Registrar of Motor Vehicles however was not notified of Mr H's medical condition and the potential dangers posed by his continuing to ride a motorcycle.
There was no statutory obligation on the deceased's treating medical practitioners to notify the Registrar of motor vehicles of the deceased's condition.
In his report to Dr L on 18th December 2008, Dr S, referring to the two episodes of unexplained running off the road which he said could not be taken lightly, concluded that "in keeping with Commonwealth guidelines he (the deceased) should not be allowed to drive for six months."
Those guidelines to which Dr S was referring were contained in a publication produced by Austroads, (the Association of Australian and New Zealand road transport and traffic authority) entitled, "Assessing fitness to drive 2003". This document is intended for use by any health professional involved in assessing a person's fitness to drive including, medical practitioners (general practitioners and specialists), optometrists, psychologists, physiotherapist, and occupational therapists. It sets out clear medical criteria of unconditional and conditional licences which form the medical basis of decisions made by the driver licensing authority. It also provided general guidance with respect to patient management including short-term situations in which patients should be advised not to drive but which do not warrant actions in terms of licensing.
The content focuses on common conditions known to affect fitness to drive. In particular, determining the risk of a patient's involvement in a serious motor vehicle crash caused by loss of control of the vehicle. The authors point out that it is accepted that other medical conditions, or a combination of conditions, may also be relevant and that it is not possible to define all clinical situations where an individual's overall function would compromise public safety. They acknowledge that a degree of professional judgement is therefore required in assessing fitness to drive and that health professionals should always keep themselves up to date with significant changes in medical knowledge and technology that may influence their assessment of drivers, and with legislation that may affect the duty of either the health professional or the patient.
Where a health professional is treating any patient who holds a licence and has a condition which may impact on their ability to drive safely, the guidelines state that the health practitioner should routinely consider the impact of a patient's condition on their ability to drive safely.
The Vehicle and Traffic Act 1999, recognises the reticence that a health professional might have in bringing to the attention of the Registrar of Motor Vehicles information relating to another person's ability to drive.
Section 63 of the Vehicle and Traffic 1999 states:
(1) A person incurs no civil or criminal liability for reporting to the Registrar, in good faith, that another person may be unfit to drive a motor vehicle or that a motor vehicle or a trailer may be defective.
Dr L was aware that the deceased chose not to follow Dr S's advice. No doubt he considered the situation but chose not to avail himself of the protection offered under section 63 (1) and report his concerns.
The Austroads publication to which I previously referred, had the following to say in relation to this very point and I set out the relevant portion.
The Health Professional- Confidentiality and Privacy
Health professionals have both an ethical and legal duty to maintain patient confidentiality.
It is recognised that the patient-professional relationship is built on a foundation of trust. Patients disclose highly personal and sensitive information to health professionals because they trust that such information will remain confidential. If such trust is broken, many patients would be likely to either forego examination/treatment and/or modify the information they give to their health professional, thus placing their health at risk.
Although confidentiality is an essential component of the patient-professional relationship, there are, on (very few) occasions, ethically and/or legally justifiable reasons for breaching confidentiality. With respect to assessing and reporting fitness to drive, the duty to maintain confidentiality is qualified in certain circumstances in order to protect public safety.
For example, in situations where the patient is unable to appreciate the impact of their condition, or to take notice of the health professional's recommendations due to cognitive impairment, or if driving continues despite appropriate counselling and is likely to endanger the public, the health professional should consider reporting directly to the Driver Licensing Authority.
That the deceased continued to drive against medical advice placing his own life and the lives of other road users at risk and that this was known to his medical practitioners, is a very serious matter and would tend to strongly suggest that mandatory reporting by health professionals be implemented.
I accept however that the there is a real possibility that mandatory reporting would only result in patients not consulting or confiding in their doctors regarding important information that may impact on their ability to drive or that they may engage in "Doctor shopping".
Mandatory reporting by health professionals is required in South Australia and the Northern Territory. In 2011, the issue was considered in Tasmania as part of a review of the older driver licensing system and rejected in favour of a better education system to health professionals and their driver patients.
Clearly however there needs to be ongoing and better education provided to the medical profession and relevant authorities and every encouragement and support given to treating health professionals to be more proactive in encouraging self reporting by their patients and in considering reporting the matter themselves where they consider that according to the guidelines, their patients ought not to be driving.
Before I conclude this matter, I wish to convey my sincere condolences to the family of the deceased.
This matter is now concluded.
DATED 26 June 2013 at Launceston in the State of Tasmania
The aforementioned findings were amended on the 5 September 2013 :
At the request of the legal representatives of the senior next of kin, I reviewed my findings in relation to the deceased's duty to report changes in his medical condition to the Registrar of Motor Vehicles. It was pointed out at the time that the deceased had renewed his licence on three particular occasions, he had not indicated the existence of any condition that may affect his ability to drive as he was unaware at that time that he had any condition that required reporting.
On reviewing my finding, I;
- Expanded the section dealing with the deceased's past medical history;
- Upon clarification with the Registrar of Motor Vehicles the section headed "duty to report", was amended to reflect the fact that the duty to report was not solely related to licence renewals and that it was the responsibility of a driver to notify the registrar as soon as practicable once they became aware of a condition that might affect their driving;
- In both the sections "past medical history" and "duty to report", I amended my findings to reflect the evidence, that it was only Dr L who was aware that the deceased was driving against medical advice. There was no evidence that Dr S was also aware.