Record of Investigation Into Death (Without Inquest)
Corners Act 1995
Coroners Rules 2006
These findings have been de-identified by direction of the Coroner pursuant to S.51(1)(c) of the Coroners Act 1995 in respect of the drivers of the other vehicles involved in this fatality
I, Glenn Hay, Coroner, having investigated the death of
Kerry John Wells
have decided not to hold a public inquest hearing into this death because my investigations have sufficiently disclosed the identity, the time, place and cause of death, relevant circumstances concerning how the death occurred 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 a public inquest hearing would elicit any information further to that disclosed by the investigations conducted by me.
I Find That:
(a) Kerry John Wells (Mr Wells) died on 8 March 2012 on the Midland Highway near Bagdad.
(b) Mr. Wells was born at Devonport in Tasmania on 21 November 1950 and was aged 61 years at the time of his death. Mr Wells resided at Penguin and was employed as a truck driver. He was divorced and father to an adult daughter.
(c) Mr. K. Wells died as a result of conflagration when the vehicle he was driving burnt as a result of a motor vehicle crash.
The driver of another motor vehicle involved in the crash and thus an interested person, whom I will refer to as “Ms Driver”, received very significant injuries in the crash including severe traumatic brain injury with significant and long-lasting sequelae including both retrograde and anterograde amnesia; severe cognitive impairment and with emotional and mental health issues including psychosis. I have accepted detailed medical evidence in relation to this driver about the potential impact upon any anticipated medical rehabilitation and possible recovery by her, of any publicity identifying her as the driver of a vehicle or any other involvement in this unfortunate crash. There are sensitive personal and medical matters involved and I believe that to publish such information would prejudice the health and wellbeing of this interested person. I have provided my formal findings inclusive of the proper name of Ms Driver, to remain on the coronial record.
However, for the reasons stated:
I ORDER that until the further order of this court, the publication of my findings to any person including to any website and including the next of kin of Mr Wells, be ‘de-identified’ to the extent that any information likely to properly identify the driver of any vehicle (other than Mr Wells) involved in the crash be deleted from the findings, AND
FURTHER, I ORDER that until the further order of this court, any person’s access to any coronial record relevant to this inquest be restricted in that any record is not to be inspected by or be provided to any person in any way to identify the driver of any vehicle (other than Mr Wells) involved in the crash whether directly or indirectly.
Findings as to the Circumstances Preceeding the Crash:
Tasmania Police conducted a very detailed investigation on my behalf into the circumstances surrounding the crash, including a detailed and comprehensive crash scene reconstruction. From that investigation and the available evidence I make the following findings.
On the morning of 8 March 2012 Mr Wells drove a Kenworth Prime Mover truck, registered number A82ZQ, and trailers from the North West Coast to the TOLL freight depot in Evans Street, Hobart. He arrived at approximately 10.50am and once at the yard his freight was unloaded. For the return trip he was allocated a refrigerated container (registered number IT-3312) for his lead trailer (A) and a Taut liner (curtain sided trailer) (registered number PT-7643) as his B trailer. A prime mover towing two trailers is known as a ‘B Double’ rig.
He left the TOLL depot, driving the unladen B double rig at approximately 11.05am and drove to the Cadbury factory at Claremont where both containers were loaded with freight for transport back to the North West Coast. He departed Cadbury at approximately 12.20pm. The gross weight of the A Trailer was 15.47 tonnes and the gross weight of the B trailer was 23.62 tonnes; weights I find that were within statutory limits and the rig was compliant in regards to dimensions and load security.
At approximately 12.55pm Mr Wells was the driver and sole occupant of his B Double rig and was travelling in a northerly direction on the Midland Highway at Mangalore. He was travelling on a straight section of road known as the ‘Mangalore Straight’. The normal speed limit is the open speed limit of 100km/h, however then existing or intended road works on the highway between Mangalore and Bagdad had reduced the speed limit, by sign, to 80km/h. An 80km/ sign for north bound vehicles was located on a grass section several metres to the west of the north bound lane on the southern end of the Mangalore Straight. The sign was not clearly visible to north bound traffic. There were no other north bound road works speed repeater signs in the area. The evidence of all eye witnesses following Mr Wells prior to the accident is that they believed the speed restriction to be 100km/h; all vehicles were travelling at a relatively constant speed at something less than that limit.
The centre road markings and edge lines had been scrubbed out in preparation for a reseal of the highway surface but notwithstanding this they were still visible to some degree. On this day there were no road work personnel in this area and there were no road works being conducted. On all available evidence Mr Wells was travelling at a speed which was between 80 and 100km/h in a proper and appropriate manner wholly within the north bound lane.
At this time Ms Driver was driving a gold coloured Mitsubishi Magna sedan in a southerly direction on the Midland Highway, from the direction of Bagdad towards Mangalore. Travelling behind Ms Driver was a dark grey coloured Mazda 3, driven by Ms M.
Ms M had been following Ms Driver’s vehicle for a distance of approximately two kilometres and during this noted that Ms Driver’s vehicle was travelling at a constant speed of approximately 60km/h and her vehicle was veering from side to side within its lane. The vehicle did not cross the notional centre line, nor did it veer off the side of the road. However, on one occasion when passing a truck travelling in the opposite direction, her vehicle was noted to drift towards the centre line and there was only approximately half a metre between Ms Driver’s vehicle and truck as they passed one another. It is to be noted Ms Driver was driving well below the speed limit for south bound traffic.
Ms Driver’s vehicle entered onto and commenced travelling along the ‘Mangalore Straight’ at a constant speed of approximately 60km/h as Mr Wells’ B double was approaching the northern end of the straight, travelling in the opposite direction.
Ms Driver’s vehicle was seen to veer onto the incorrect side of the road, by at least half the width of the vehicle, without deviating in speed and directly into the path of the B double rig being driven by Mr Wells. It is clear from all available evidence that Mr Wells had insufficient perception and reaction time to take any form of evasive action and the front driver’s side of the prime mover collided with the front driver’s side of the Magna driven by Ms Driver.
Subsequent to impact Mr Wells lost control of the steering of the prime mover and the B double rig continued north bound, crossing to the incorrect side of the road where it struck and slid along an embankment. The impact caused the two trailers to roll onto their left hand side, causing the prime mover to overturn onto its roof. Both trailers and the prime mover came to rest 140 metres north of the point of impact with Ms Driver’s vehicle.
The prime mover was immediately engulfed in flames. Mr Wells was unable to remove himself from his vehicle and was incinerated by the conflagration.
As a result of the impact Ms Driver’s vehicle was extensively damaged. She was extricated and conveyed to the Royal Hobart Hospital in a critical condition. The speedometer in her motor vehicle was stopped as a result of the severe impact and registered 60kph. There is no evidence this vehicle or the B double was under any braking prior to, at the time of or directly following the time of impact.
Ms M had been unable to stop her vehicle prior to travelling through the crash scene and her vehicle was struck by Ms Driver’s vehicle as it spun out of control. As a result of this impact Ms M received superficial injuries. There is no evidence her vehicle was travelling at any excessive speed at any relevant time.
On 9 March 2012, Forensic Pathologist, Doctor Don Ritchey performed a post mortem examination of Mr Wells during which he determined the cause of death to be conflagration, due to a motor vehicle crash. Conflagration is described as “a great and destructive fire that threatens life.” I accept the opinion of Dr Ritchey that Mr Wells his death was a direct result of the fire and not from injuries sustained in the crash.
Findings Arising From Investigations Subsequent to the Crash:
The regional fire investigator for the Tasmania Fire Service, John LING, attended the scene of the crash and subsequently prepared a report in relation to the origin of the fire. In his opinion the right hand side fuel tank of the prime mover was damaged in the initial contact between both vehicles and when the truck finally came to rest the remaining fuel emptied onto the hot components of the engine and therefore reaching its automatic ignition temperature. He found no evidence of a deliberate fire cause and therefore determined it to be accidental in nature. I accept and adopt those onions.
The prime mover and trailers driven by Mr Wells at the time of the crash were examined by transport inspectors from the Department of Energy, Infrastructure and Resources (D.I.E.R.). This inspection determined that from all available evidence the trailers, prior to the crash, were all in a road-worthy condition. However, the inspector in charge was unable to formulate any opinion as to the condition of the prime mover due to fire damage. I accept and adopt the opinions of the DIER inspectors. There was no evidence discovered to suggest the prime mover was not in a road worthy condition.
An inspection was also carried out on the Magna sedan driven by Ms Driver at the time of the crash. This inspection determined that while the vehicle suffered extensive damage in the crash, it appeared it was in a well-maintained and roadworthy condition at the time of the crash.
An inspection was also carried out on the Mazda 3 Sedan, driven by Ms M at the time of the crash and determined that it was in a road worthy condition prior to the crash.
At the time of the crash the weather was overcast but fine and weather conditions did not impact on the circumstances surrounding this crash.
The section of the highway where the crash occurred is constructed of a bitumous material and while it was under re-construction the road markings were still visible and the road surface itself was in a fair condition. While a newspaper article, published in The Mercury newspaper on 28 March 2012 indicated the poor condition of the highway at the time of the crash, I find that highway conditions did not impact on the circumstances surrounding the outcome of the crash.
There was nothing in any toxicology reports in relation to any relevant person to suggest alcohol or drugs impacted at all on the circumstances surrounding the cause of the crash.
At the time of the crash Ms Driver was aged 43 years and resided with her husband and daughters at Bagdad. She was the holder of a full and active Tasmanian driving licence and was required to wear visual aids when driving. The medical condition of epilepsy was incorrectly recorded on her current licence and she was next required to provide a medical fitness assessment on 1 November 2012.
Ms Driver had a medical history of depression, hydrocephalus, migraines, fainting and progressive cognitive deficit. At the age of 21 she had a shunt inserted which was regularly reviewed by the Department of Neurosurgery at the RHH. It was noted by her general practitioner that if her intracranial pressure increased she would become dizzy and develop a headache and confusion but no seizure or black-out or collapse according to him.
In October 2004 when Ms Driver applied to renew her driver licence for a period of three years, she indicated ‘yes’ to suffering from giddy attacks and ‘no’ to a number of other disorders which included epilepsy. Ms Driver’s drivers licence was renewed without a request for a ‘medical fitness to drive assessment’ being made by the Registrar of Motor Vehicles.
In February 2008 when Ms Driver applied to renew her driver licence for a period of 5 years she indicated ‘yes’ to having suffered from giddy attacks and ‘no’ to the other disorders. On this occasion the Registrar of Motor Vehicles wrote to Ms Driver requesting that she undergo a ‘medical fitness to drive assessment’ in order for her to keep her driver’s licence.
In May 2008 the Registrar of Motor Vehicle received a medical report and certificate indicating that she was fit to drive a motor vehicle at ‘private standards’. Ms Driver was subsequently advised that she would be required to provide ‘medical fitness assessment’ reports every 12 months to keep her driver licence. She did this for renewals in 2009, 2010 and 2011.
In 2008 the Registrar of Motor Vehicles updated her drivers licence to indicate that she suffered from epilepsy, however this medical condition was incorrectly recorded and this error has been acknowledged since by the The Secretary of the Department of Infrastructure Energy and Resources. Notwithstanding this and because Ms Driver had suffered from giddy attacks the Registrar would have still required her to undertake yearly medical assessments, however there is no record on her licence history as to when and/or where she suffered her last giddy attack.
Her consultant psychiatrist reported that following 2009 Ms Driver a suffered significant difficulty with memory and concentration and in the opinion of that doctor is was presumed due to the accumulated effects of trauma to her brain. Ms Driver was unable to return to work at that time and became a Disability Support Pension recipient. Ms Driver was able to function reasonably well despite continuing migraines and short term memory problems which seemed to be getting worse. Described by her consultant psychiatrist as ‘progressive cognitive deficits.’
In October 2011 Ms Driver reported to her general practitioner that she had had episodic dizziness, photophobia and vomiting when she had a migraine, but reported she had never had a collapse or seizure to that point in time. She was not on any anti-convulsive medication and not depressed at that time.
In November 2011, whilst at home Ms Driver suffered what was thought to be a seizure, but cause unknown. This seizure was associated with jerking movements and loss of consciousness however no conclusive diagnosis in relation to the event was made.
On 6 March 2012 Ms Driver saw her consultant psychiatrist who had been treating her since 1999. She reported finding the process of selling the family home to be stressful, and she was having a lot more migraines and fainting, but no more seizures. She was prescribed a low dose of the drug ‘Valproate’ to assist with her anxiety and migraines. The drug is an anti-convulsant but it was not prescribed on this occasion for that reason. She took one that night but upon waking the following morning she felt unbalanced and unsteady on her feet. She discontinued its use after one dose and the adverse symptoms settled. Her husband attempted to report the cessation of the drug to the consultant psychiatrist the next day, leaving a message to that effect.
Her husband indicated that in the past she had suffered epilepsy in the form of ‘partial absence seizures’, though he cannot recall who actually diagnosed the disorder. In the months leading up to the crash she suffered what he considered to be partial absence seizures on at least two occasions. The first occurred at Kingston Beach when she was walking the dog and at the time she did not know where she was or what she was doing. The second occurred approximately 3 to 4 weeks prior to the crash and on this occasion she was at home. She was noted to be staring into space and was not cognisant of dialogue or responding to visual movement, although conscious. After approximately 90 seconds her husband shook her by the shoulder and this brought her out of the condition. On neither occasion was medical assistance and/or management sought.
On 8 March 2012 Ms Driver spoke with her husband from home by telephone, approximately 30 minutes prior to the crash. During this conversation she sounded fine and indicated it was her intention to go shopping during the course of the afternoon.
Analysis of a sample of blood taken from Ms Driver at the Royal Hobart Hospital shortly after the accident indicated the presence of several drugs, including morphine, midazolam, lignocaine and ketamine. Their presence is explained in that they were administered post-crash in a para-medical environment. Other drugs detected were desmethylvenlafaxine, diazepam and valproic acid, all of which were legally prescribed to her and in a concentration not displaying any concern.
Ms Driver has been taking the desmethylvenlafaxine regularly ever since 2009 and studies indicate that this drug has not been shown to cause significant adverse effects to driving ability. In any event, due to her consistent use of this drug she would have gained a tolerance and any potential side-effect would have been greatly diminished.
Diazepam was a prescribed drug that Ms Driver took when she felt stressed. The concentration detected following crash was at a therapeutic level and it would seem likely she has also been taking it for a lengthy period of time and any potential side-effect would also be diminished however when taken in combination with other central nervous system depressants the sedative effects of the drug can be enhanced. In this case the other central nervous system depressants detected were morphine and valproic acid.
Valproic acid was originally prescribed to Ms Driver two days before the crash to help her with anxiety and headache issues. She ingested one 200mg tablet that evening and then went to bed. The following morning she complained of feeling as though she was drunk - unsteady on her feet, unbalanced and confused. She thought the medication was the cause of this and she stopped the medication immediately. She did not take any further tablets and by the morning of the crash she was not complaining of any further adverse effects. An amount of Valproic Acid was detected in her blood is the smallest concentration that can be reported and is probably consistent with taking a 200mg tablet on the evening of the 6 March, approximately 40 hours prior to the crash. It is highly unlikely the ingestion of this drug had any adverse effect on her driving immediately before the crash.
In my view there is insufficient cogent evidence to establish, having regard to her medication regime, that the two drugs in combination at the levels detected would have adversely affected her driving ability. Taking into account all the circumstances of the case I am of the view there is insufficient evidence to determine as a matter of fact, that Ms Driver was affected to any degree by the drugs she had ingested prior to her driving on 8 March 2012.
Ms Driver received significant cognitive and physical injuries as a result of the crash including ‘post traumatic amnesia’ and has no recall of the circumstances leading up to or surrounding the crash. It is highly unlikely she will ever regain that memory and highly unlikely she will drive a motor vehicle again.
The Director of Public Prosecutions has reviewed the entire factual matrix and recommended that that no criminal charges be laid against Ms Driver on the basis it would not be possible to prove beyond reasonable doubt her vehicle crossed to the wrong side of the road as the result of a conscious act of driving. While inattentive driving may have been a cause, other factors such as medical events and other non-conscious reasons could not be excluded to prove a case beyond reasonable doubt.
I must consider this case from the perspective of determining whether the crash was caused or contributed to by any person on the balance of probabilities, or in other words a reasonable likelihood.
What is entirely clear is that Ms Driver was driving a motor vehicle and it went to the incorrect side of the highway and collided with Mr Wells’ B double. The manner of Ms Driver’s driving immediately prior to the crash and the reason she crossed to the incorrect side of the highway cannot be properly explained. There is no evidence to suggest she was speeding or affected by alcohol or drugs. She has no memory of the events as a result of her significant crash injuries.
A number of probabilities exist as to why she crossed to the wrong side of the road such as –
• Mechanical event leading to loss of control. There is no evidence to support this. I have found that neither speed, alcohol nor drugs were factors in the crash. All vehicles were in appropriate and safe working order and nothing in the road or weather conditions could be said to have caused or contributed to the crash.
• Loss of control due to distraction, such as reaching for or using a mobile telephone or other device, a coughing or sneezing fit or the presence of an insect. None can be ruled out, however there is no evidence she was using a mobile telephone or otherwise distracted by any person or thing.
• Inattention. Other than inferences possibly to be drawn from the observed facts surrounding the crash, there is no direct evidence of this.
• Falling asleep at the wheel. This cannot be ruled out given that she was driving on a main highway at a speed less than what might otherwise be expected and she was observed to move within her lane and then drift over the centre line on one occasion before again drifting into the path of the B double a short time later. This might be said to be consistent with a person dozing off. On the other hand there is no evidence to suggest that she might have been unnecessarily tired or sleep deprived at the time. She seemed fine to her husband during the telephone call 30 minutes prior to the crash.
• Seizure activity; episodic dizziness; so-called partial absence seizure or dizziness in being non-responsive to time and place; fainting or loss of consciousness; severe migraine episode coupled with photophobia, well known to affect visual and cognitive acuity especially in the very early stages of attack. She has a medical history of all of these events and she had disclosed episodes of dizziness when applying for drivers licences but had received medical assessment clearance to drive. None of these factors can be ruled out and they may well be consistent with her reported manner of driving and one or more of them are more likely than other suggested causes to be the reason she drove as she did to this fatal and tragic crash.
While I cannot be certain, I am of the view that from all available evidence it is likely Ms Driver was acting in a state of disassociation immediately prior to the crash and had limited or no conscious control over her manner of driving. The only apparent likely explanation is that she has suffered some form of medical episode which has resulted in her veering within her lane and then to the incorrect side of the road which caused the crash and the tragic death of Mr Wells.
This is a timely opportunity to remind all medical practitioners of their obligation, not only to their patient but to the broader public safety, to disclose to the Registrar of Motor Vehicles relevant information relating to illness or injury likely to impact upon that patient’s ability to properly and safely drive a motor vehicle or other machinery where the public might be exposed to potential risks.
I have already noted that there was an extensive and exhaustive investigation into this crash and I wish to acknowledge and thank all persons who assisted at the crash scene in very traumatic and difficult circumstances, as well as those who have assisted since. I especially wish to acknowledge the assistance of Tasmania Police Officers; Midlands District Fire Officers; Tasmania Fire Services Officers; Tasmania Ambulance Officers; Transport Inspectors; TOLL employees; members of the public who assisted at the crash scene; Sergeant Rod Carrick and Senior Constable Kelly Cordwell of Crash Investigation Services.
In closing I wish to convey my sincere condolences to the next of kin, family and friends of Mr. Wells.
DATED: 14 May 2013 at Hobart in the State of Tasmania.