Record of Investigation into Death (Without Inquest)
Coroners Act 1995
Coroners Rules 2006
The Findings below have been edited to remove identifying features of the deceased at the request of the next of kin and with the approval of the Coroner
I, Rod Chandler, Coroner, having investigated the death of
WITHOUT HOLDING AN INQUEST
The "deceased" died in December 2008 on Midland Highway near Jericho.
The "deceased" was aged 26 years. He was unmarried and a student.
I find that "the deceased" died of multiple blunt traumatic injuries as a result of a motor vehicle crash.
Circumstances Surrounding the Death: -
The Crash and death
At about 7.20pm in December 2008 "the deceased" was driving a Honda sedan in a northerly direction on the Midland Highway. At the same time a truck driver was travelling south on the Midland Highway. He was driving an Iveco prime mover. It was towing two trailers. At a point approximately 300 meters south of the Stonor Road turnoff the Honda moved from the northbound lane into the southbound lane causing it to come into collision with the prime mover. The collision caused "the deceased" to be ejected from the Honda. It then caught fire.
At approximately 7.30pm Dr Robert Simpson responded to a Tasmania Ambulance Service pager and attended the crash scene. He examined "the male person" and was satisfied that he was deceased.
Subsequently, a post-mortem examination was undertaken by Forensic Pathologist, Dr Donald Ritchey. In his opinion the cause of "the males death was multiple blunt traumatic injuries sustained in the crash. Dr Ritchey also noted that a probable significant contributing factor was depression.
A toxicology report upon post mortem-blood indicates the presence of venlafaxine in a greater than therapeutic range. However, it was noted that the blood specimen was collected from the chest cavity and therefore the drug concentration may have been elevated due to post-mortem redistribution. Venlafaxine is used in the treatment of major depression. Testing was negative for alcohol.
The Crash Investigation
An investigation into the circumstances of the crash was undertaken by Tasmania Police. Its salient findings were that:
At the time of the crash the weather was fine, the traffic was light and it was daylight. The position of the sun was to the west and would not have affected the vision of either driver. There was no evidence to suggest that weather or atmospheric conditions were contributory factors.
The road surface was bitumen, in good condition and clearly marked. There were gravel edges and grass verges at least 15 metres wide on either side of the highway.
The road approaching the Stonor turnoff is wide with single lanes in both directions.
There were no significant obstructions to driver visibility. In particular, there were no trees lining each side of the highway and no issues with shading of the roadway. There were no damp patches and no precipitation at the time of the crash, or within the preceding 24 hour period.
The Midland Highway, in the area of the crash, was subject to a 110 kph speed restriction. There was no evidence to suggest that excessive speed contributed to this crash.
There was no evidence of tyre markings on the roadway to indicate that immediately prior to the crash the Honda had been subject to heavy breaking.
Evidence at the scene clearly showed that the truck driver had commenced heavy breaking at least 20 metres prior to impact and had steered the prime mover to the left of the roadway in an attempt to avoid the crash.
The point of impact was identified as being in the centre of the southbound lane.
There were no known independent eye-witnesses to the crash. However, the truck driver described it having occurred in these circumstances:
"…….as I was coming around the sweeping corner at the Stonor turnoff on the Midland Highway I noticed a car which looked like it was an iridescent green colour and it took my attention as it was swaying side to side and getting pretty close to the white centre dividing line on the road. I then saw the car cross the centre dividing line and come directly towards me. I noticed that the driver of the car had both hands on the steering wheel at the time. I immediately knew that the car was going to hit me so I swerved to the left and applied the foot brake to try and avoid a collision as the way the car was coming at me I thought it was going to hit fair in the middle of the prime mover. The car then collided with the front drivers side of the prime mover and I felt the truck lift up and heard a loud bang which sounded like a tyre blow out."
- An inspection of the Honda revealed extensive damage by post-impact fire and its pre-crash condition could not be determined. However, the vehicle was owned by "deceaseds" brother and he reports that in his opinion the Honda was in a roadworthy condition with good tyres and its brakes and steering in proper working order.
- An inspection of the prime mover showed it to have been in a roadworthy condition prior to the crash and that it was operating within correct load parameters.
- A sample of the drivers blood was taken after the crash and analysed for drugs and alcohol. The results were negative.
- Telephone records reveal that neither driver was using a mobile telephone at the time of the crash.
- It could not be determined whether "the deceased" was wearing a seat belt at the time of the crash because of the fire damage to the Honda. However, "the deceased" was ejected from the vehicle after of the crash indicating that he may not have been wearing a seat belt.
- "The deceased" was an experienced and competent driver. He did not suffer from any disabilities or known illnesses which would compromise his capacity to drive.
Other Relevant Matters.
"The deceased" had suffered from depression extending back to at least 2003 when he was admitted to hospital for treatment. His brother described him as being "often quiet and introverted" and that at times "he would usually go really quiet and mope around." However, he had never known "the deceased" to threaten self-harm and he did not believe he would take his own life. "the deceaseds" father also described his son as "introverted" but had never known him to have "threatened to take his own life."
"The deceased" and his girlfriend had been in a personal relationship since about mid-2007. In September 2008 his girlfriend ended the relationship. It seems that "the deceased" had difficulty accepting this. According to his former girlfriend he was "becoming depressed." She encouraged him to seek medical help.
In October 2008 "the deceased" attended Dr Scott Macrossan. He complained of symptoms of depression. He was referred to Consultant Psychiatrist, David Weidmann whom he saw the following day. Dr Weidmann diagnosed "the deceased" to be suffering from a dysthimic disorder which he describes as a "type of depression that tends to be mild to moderate, but recurrent." Dr Weidmann noted that "the deceased" denied thoughts of suicide or self-harm. He prescribed venlafaxine (75 mg in the morning) and advised a review appointment in two weeks. "The deceased" re-presented on October. On this occasion Dr Weidmann noted that "the deceased" had had a subjectively good response to the anti-depressant. He reported that he was back to his usual self, had been feeling happier and was thinking clearly and coping better. "the deceased" further reported that he was very optimistic about his improvement and did not want ongoing management.
In November 2008 "the deceased" attended Dr Richard Climie in the absence of Dr Macrossan. He arranged for "the deceaseds" admission to St Helens Private Hospital ("St Helens") under the care of Dr Weidmann. In his referral letter to Dr Weidmann, Dr Climie noted that "after initial improvement with Efexor ("the deceased") has gone down hill again and really not coping very well with some thoughts of self harm."
Later in November 2008 "the deceased" was assessed by Dr Weidmann at St Helens. On mental state examination it was noted that "the deceased" expressed some thoughts of self-harm/suicide but rated himself "a zero risk." He was diagnosed with major depression. It was resolved to formally admit him and his venlafaxine was increased to 150 mg per day.
According to St Helens progress notes "the deceased" left the ward at 4.30pm on 27 November to see a movie and have dinner with a friend. He returned at 8.30pm. However, he discharged himself shortly afterwards and it was noted that he was going home with his girlfriend and that he intended the following day to make an appointment to see Dr Weidmann. However, "the deceased" did not make that appointment.
It seems that "the deceased" held some hope that his relationship with his girlfriend could be resurrected. However, on 8 December, after a heated argument, his former girlfriend made it clear that the relationship was definitely at an end.
In December, his former girlfriend, after receiving numerous text messages from "the deceased", agreed to meet him at his residence. She arrived there at about 5.45pm. It is her account that she became uncomfortable with the conversation not long after arriving. She went to leave and "the deceased" then assaulted her by pushing her onto a couch and holding her by the neck so that she could not breathe. He then pressed a cushion against her face and she "blacked out." Afterwards, when she "woke up" "the deceased" was sitting next to her on the couch. He "started crying and broke down. He said he had to get out of there, grabbed his keys and left."
His former girlfriend then returned to her mothers house. She telephoned the police and officially reported the assault. It was not until about midnight that she learned of the crash and "the deceaseds" death. Telephone records show that "the deceased" attempted to make phone contact with his former girlfriend on five occasions after he left his residence and before the crash.
His former girlfriend says that after she ended their relationship "the deceased" did, on three occasions, threaten to commit suicide.
I am satisfied that a thorough and detailed investigation has occurred into the death of "the deceased" and that there are no suspicious circumstances.
I accept the opinion of Dr Ritchey and find that "the deceased" died as a result of multiple blunt traumatic injuries sustained in a motor vehicle crash.
It is clear upon the evidence that the crash occurred because the Honda moved from the northbound lane into the southbound lane and into the immediate path of the prime mover being driven by the truck driver. The circumstances of the crash and those events preceding it do give rise to the question whether "the deceaseds death arose because he deliberately drove the Honda into the path of the prime mover with the intention of causing himself fatal injuries and was thus a consequence of suicide.
I am mindful that a finding of suicide should not be presumed as the likely explanation for "the deceaseds" death. Instead, I need to be positively satisfied upon the evidence that the death has resulted from an act of suicide. In this case, it is my opinion that the evidence does clearly establish this to be so.
Two months prior to his death "the deceased" had been diagnosed with a depressive illness. Just two weeks prior that diagnosis was confirmed and his illness was considered sufficiently serious to warrant its monitoring in hospital. At this time "the deceased" had acknowledged thoughts of self-harm. "The deceaseds" illness had manifested itself at a time when his relationship with his girlfriend was in turmoil and, from her viewpoint, was at an end. It is clear that "the deceased" had difficulty coping with the breakdown of this relationship and he had, at this time, indicated to his girlfriend an intention to take his own life. It must have been apparent to "the deceased" that any prospect of the relationship being resurrected was lost when he assaulted his girlfriend in the incident at his home on the afternoon of the crash. That incident caused him to be emotionally distressed. Less than two hours later the fatal crash occurred.
The crash took place in daylight on a fine day and on a roadway in good condition. "the deceased" was an experienced and competent driver. His driving capacity was not affected by alcohol or other illicit substance. He was not driving at an excessive speed so to cause a loss of control. He was driving a vehicle with no known defects. Moments before the crash he was not using his telephone and both his hands were observed to be on the steering wheel. Importantly, there is not any evidence of "the deceased" braking or taking other evasive action to avoid the collision. All these matters, when viewed together and considered in the context of "the deceaseds" depressive illness and the assault incident involving his girlfriend lead me to conclude that the crash occurred because "the deceased" deliberately drove the Honda onto the southbound lane of the Midland Highway and into the direct path of the truck drivers prime mover. I am satisfied that "the deceased" acted in this manner with the intention of sustaining life-ending injuries.
It is important that I record that the evidence shows that the truck driver was, at all times, driving in a proper manner and that his driving did not, in any way, contribute to the crash.
I conclude by conveying my sincere condolences to "the deceaseds" family.
DATED: Monday, 18 January 2010 at Hobart in the State of Tasmania.