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 details of senior next of kin of the deceased by direction of the Coroner pursuant to S.57(1)(c) of  Coroners Act 1995.

I, Reg Marron, Coroner, have investigated the death of Baby R

For the reasons set out in this finding, I am not of the view that there is a requirement to hold an inquest. I 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.

Find That:

The deceased idenitifed as Baby R died on the 20th June 2011 at Railton. 

Baby R was born in Latrobe in September 2008 and was aged 2 years and 9 months at the time of her death.

Baby R died as a result of multiple blunt traumatic injuries sustained from a motor vehicle crash.

Circumstances Surrounding the Death: 

The deceased Baby R is the youngest daughter of Ms K. Ms K, her oldest daughter and Baby R resided with Ms K’s partner, Mr S, at Railton.

On the morning of Monday 20 June 2011, Ms K, Mr S and Baby R, went across the road to the home of Mrs K, the grandmother of Baby R. It had been arranged that she would drive them all to Devonport.

Mrs K was the owner of a 1999 Holden Commodore Station Wagon. There was a child restraint seat mounted behind the front passenger seat of the vehicle. Ms K said that she placed Baby R in the seat and Mr S, who was seated in the rear driver’s side seat, fastened the seat belt over Baby R and the child restraint seat. Ms K then sat in the front passenger seat.

At the time of leaving Railton it was raining and the road was wet. Mrs K knew the area well as she had lived there for most of her life. She said that she was in no rush and was travelling at 80 km/h.  As they were heading in the direction of Devonport and approaching the Youngman’s Road intersection, they came across a friend, Mr W, who was parked on the side of the road.  Mrs K stopped and Mr W told them that he had run out of petrol.   Mrs K decided to go back to Railton to get some petrol for him.   There was some to-ing and fro-ing when Mrs K returned to Mr W thinking that Mr W’s girlfriend may have been going to assist him, but when this did not eventuate she once again started to drive back to Railton to get fuel for Mr W.

At this point the rain became heavier and the road was very wet. Mrs K stated that as they were driving, she was talking to her daughter and then she lost control and remembered going up the road sideways and seeing a van coming towards her. Mr S described that he felt the back of the car go to the right and he heard the tyres squeal. The car then flicked the other way and the tyres squealed loudly. Ms K has no memory of the crash.

Mr R, aged 62, was driving a white 2004 Mazda Commercial Van, from Railton towards Devonport to collect some electrical items for work. His vehicle was loaded with electrical equipment inside as well as an extension ladder and conduit on the roof racks of the vehicle.

As he travelled over a small crest in a northerly direction at 90km/h he could see a light coloured vehicle coming around a corner and sliding towards his vehicle.  He braked heavily and attempted to go to the right side to avoid a collision. At this stage the vehicle being driven by Mrs K spun back around and the left side of the vehicle was travelling towards Mr R’s vehicle. The vehicles collided and the van travelled a 180 degree circle into the right hand lane. Mr R was trapped in the vehicle and unable to free himself.

The Crash Scene

The Holden Station Wagon driven by Mrs K was torn in two by the impact, both sections coming to rest on the western side of the road. Mrs K looked into the rear section of the vehicle but was unable to see her granddaughter.  Ms K was still seated in the front passenger seat.

Mr B was the first to come upon the scene. He saw the Commodore Wagon broken in half.  He saw Baby R hanging upside down on a wire fence 5 meters from the rear of the car. He checked her and found no pulse. He found Mrs K on the ground at the rear of the car. Ms K was still seated in the front passenger seat and Mr S was sitting up near the rear of the front section of the Commodore wagon.  Mr B spoke to Mr R, the driver of the white Van, who was injured and trapped in the vehicle. He called 000. Other motorists came along and assisted. A short time later emergency personnel arrived and treated the occupants of both cars who were all taken to hospital. Accident Investigation Service from Burnie and Forensic Services attended.

Autopsy Results

Dr Donald Ritchey conducted an autopsy on Baby R.  He found that the cause of death was as a result of multiple blunt traumatic injuries sustained in a motor vehicle crash. Toxicology tests conducted on both drivers revealed nothing of significance as was the result for Baby R.

Vehicle Inspections

Both vehicles involved were examined at the Wivenhoe Police Compound by Mr Phillip Evans a Transport Inspector with the Department of Infrastructure Energy and Resources and Crash Investigator Constable Sven Mason who attended the crash scene and the police compound.

The Mazda E 2000 Van

The vehicle driven by Mr R, a Mazda E 2000 Van was examined and classed as mechanically sound.  It was found that the van did not reveal any fault that could have caused or contributed to the collision.

The Holden Station Wagon

The vehicle driven by Mrs K was a Holden Commodore VT wagon 1999 model and had been driven 297,762 km up until the time of the crash. She stated that she had only had the car for around six weeks having purchased it privately for $2000. Nothing had been done to the vehicle since it was purchased. She said she intended to fit another set of wheels and tyres at a later date and that she already had another set of rims. She also planned to have the car serviced.

Upon inspection the vehicle was found to be un-roadworthy due to inadequate tread depths on the left front, and both rear tyres. Regulation 55 of the Vehicle and Traffic (Vehicle Standards) Regulations 2001 requires a minimum of 1.5 mm tread depth in a continuous band around the circumference of the surface of the tyre which normally contacts the road.

The rear left tyre was the worst to the extent that there was no tread at all on the inner and middle portions with canvas beading evident around the whole circumference on the inner portion of the tyre. The tyres fitted to the vehicle were of three different makes and models as were the rims. All tyres were of the type described as “directionally fitted”, meaning that they could only be fitted correctly to the rim in one specific way. Again on the front left and both rear wheels, the tyres were incorrectly fitted backwards making it an illegal fitting. The spare tyre was observed to have poor tread pattern but was correctly fitted directionally.

Constable Mason stated that given the wet conditions at the time that it was possible a vehicle with inadequate tread on its tyres travelling at a speed appropriate to the road design or even at a lesser speed, might lose control in those conditions due to the tyres’ inability to disperse excess water away from the portion of the tread that came in contact with the road and also due to a loss of traction with the road surface in wet conditions. He stated that directional tyres fitted incorrectly to the vehicle would mean that the tyre would keep the excess water under the wheel and not disperse it to the front and sides. This would result in the vehicle attempting to aquaplane itself as it was travelling forward. He described aquaplaning as when a thin film of water gets between the tyre on the road surface causing the tread to loose contact with the service and dropping the available friction to a dangerously low level. The aquaplaning wheel and tyre would slow causing steering and control to eventually be lost. Normal braking and steering usually had an adverse effect and that a gradual speed reduction might allow a driver to regain control.

Mrs K said that she was unaware that the wheels fitted to the Commodore were smooth and were directional and fitted incorrectly. There is no doubt however that had Mrs K had the vehicle checked by a professional tyre fitter, the deficiencies in the tyres would have been immediately identified.

The Child Restraint Seat

The child restraint seat was a styrofoam “Babylove” forward facing child booster seat model 828. Information on the base of the booster seat stated that the seat was only to be used with a lap sash seatbelt or with a seatbelt and a child harness for a child weighing 14 kg to 26 kg. While it met Australian safety requirements AS/NZS 1754, the booster seat was found to be non- compliant for a child aged between 6 months to less than 4 years old which required a forward facing child restraint that had an inbuilt harness. The main crash impact point on the Holden Commodore wagon was the area where Baby R was seated. The left rear seat belt tongue was found to be still locked into the receiver; however the seat belt webbing had been torn from under the seat near the floor giving some indication of the force of the crash.

Comments and Recommendations: 

I find that the crash that resulted in the death of Baby R, occurred due to a combination of the weather conditions at the time that produced heavy rain and a very wet road surface together with the state of three of the four tyres on the Holden Station Wagon driven by Mrs K, specifically the lack of minimum tread depth and the incorrect fitting of the tyres on three of the wheels.

The result was that Mrs K lost control of her vehicle and collided with the vehicle being driven by Mr R. The impact of the crash killed Baby R and caused injury to Mrs K, Ms K, Mr S and Mr R who all required to be taken to hospital. 

Mrs K was charged and appeared in the Devonport Court of Petty Sessions for using a vehicle in contravention of vehicle standards - unsafe tyre defects - and also permitting a passenger aged 6 months or older but not less than 4 years to be unrestrained. She pleaded guilty to both charges subsequently being fined a total of $450.00, accumulation of 3 demerit points and associated costs. 

It is a timely reminder that it is the responsibility of all car owners to ensure that their vehicles are in a safe and roadworthy condition at all times in every aspect, particularly in this case, in relation to the correct fitting of tyres and compliance with the minimum tread requirements.

Given the force of the crash and the point of impact, it is possible that even if the correct style of child restraint had been used, Baby R still may not have survived such a massive collision from the side.

Mrs K was not aware that the tyres on her vehicle were directional tyres incorrectly fitted and she was also unaware of legislation changes relating to child restraints and the type of restraint required. 

I find no fault in the actions of the other driver involved, Mr R. He was travelling at an appropriate speed and he did what he could to avoid a collision. Unfortunately he was not able to do so and was injured as a result of the impact.

Before I conclude this matter, I wish to convey my sincere condolences to the family of Baby R.

This matter is now concluded.

DATED: 10  February 2014 at Hobart in the State of Tasmania.


Reg Marron