Coronial findings (decisions) 2017

Response received from WorkSafe 12 March 2024

There are two recommendations from this report that relate directly to WorkSafe Tasmania:
5. I recommend that interested parties, including the FCAI and State and Commonwealth industrial safety authorities, work collaboratively with a view to initiating the process of implementing a safety and design standard for quad bikes that is in the terms of the relevant American National Standards Institute (ANSI) standard applying for the time being; and, pending implementation of any such standard by Standards Australia, any quad bikes imported into Australia should comply with the applicable ANSI standard; and
6. I recommend that Commonwealth and State industrial safety authorities work collaboratively with other interested parties to develop a star rating system to assist in the reduction of serious injury and deaths to users of quad bikes.
Quad bikes are a significant cause of death and serious injury on Australian farms and are a significant cause of death and injury for recreational users. The majority of fatalities are due to collisions or roll-overs.
Since the release of Coroner Cooper’s findings, the Tasmanian Government and WorkSafe Tasmania has worked to implement several initiatives that prioritise and improve the safety of quad bike users in workplaces and address the recommendations of the report.

Tasmania’s Work Health and Safety Legislation

Under the general hazard and risk management provisions of the Work Health and Safety Act 2012, persons conducting a business or undertaking (PCBUs) are responsible for managing to health and safety risks associated with quad bikes. This includes ensuring quad bikes are maintained in good working order and safe condition, choosing the right vehicle for the task and physical environment, providing workers with training and information on the safe use and operation of quad bikes, ensuring safe work procedures are in place for example, operators must tell someone where they plan to go and when they expect to return, and ensuring operators always wear a helmet and other protective clothing.
In December 2021, the Work Health and Safety Regulations 2012 were amended to introduce Regulation 216A of the Work Health and Safety Regulations 2022 which requires PCBUs with management or control of a quad bike to:
* ensure an approved helmet is available for use with the quad bike.
* ensure the person using the quad bike has appropriate training.
* ensure the quad bike is not used to carry a passenger unless designed for that purpose.
This regulation also requires a user of a quad bike to:
* have had appropriate training.
* wear an approved helmet.
* not carry a passenger unless the quad bike is designed for that purpose.
The proposed introduction of a consumer code of practice for quad bike resellers in Tasmania was superseded by the introduction of the mandatory safety standard for quad bikes in October 2019 by the Commonwealth under Australian Consumer Law.

Australian Consumer Law

The Commonwealth’s Consumer Goods (Quad Bikes) Safety Standard 2019 came into effect on 11 October 2019. The purpose of this standard is to prevent or reduce the risk of fatality or injury associated with the use of quad bikes and sets out the requirements for new quad bikes and imported second-hand quad bikes.
From 11 October 2020, all new and imported second-hand quad bikes are required to:
* meet the specified requirements of the US standard for quad bikes, ANSI/SVIA 1-2017, or the European standard for quad bikes, EN 15997:2011.
* have a rollover warning label affixed so that when the quad bike is used, it will be clearly visible and legible.
* provide information in the owner’s manual or information handbook on the risk of rollover.
* be tested for lateral static stability, and display the angle at which the quad bike tips on to two wheels on a hang tag.
* have a spark arrestor that conforms to the Australian Standard AS 1019-2000 or the US Standard 5100-1d.

From 11 October 2021, general use quad bikes must also:
* have an operator protection device (OPD) to help protect riders from the risk of serious injury or fatality as a result of being crushed or pinned in the event of a rollover by holding the quad bike off the ground.
* meet minimum stability requirements.

Quad Bike Safety Rebate Scheme
On 1 July 2019, the Government commenced a rebate scheme to encourage farmers to fit operator protection devices to quad bikes. Originally planned for twelve months, the rebate scheme was extended until 10 October 2021, the day before rollover protection became mandatory under Australian Consumer Law, for new utility or general use quad bikes, and those that are imported second hand.
The scheme provided rebates for the purchase of more than 265 devices.
When the Quad Bike Safety Scheme closed in 2021, sole traders, small and medium businesses in Tasmania’s agriculture sector continued to be able to seek a rebate for the purchase of operator protection devices as part of the Government’s Primary Producer Safety Rebate Scheme, which ran from 10 October 2021 to 30 June 2022. Under this scheme, 62 rebates were paid for purchases to improve quad bike safety on farms. An additional seven rebates were claimed for approved training courses.
Rebates were paid for items such as:
* Quadbar Operator Protection Devices.
* Helmets (meeting appropriate standard).
* ATV Lifeguard Operator Protection Device.
* Rollover protection structures (ROPs), and run-over protection devices for tractors.
* Side-by-side vehicles designed for agricultural use.

Safe Farming Tasmania

The Safe Farming Tasmania (SFT) program was launched in 2014. The SFT program was designed to raise awareness of farm safety issues state-wide and is a joint initiative between WorkSafe Tasmania and the Department of Natural Resources and Environment. It has been modelled on WorkSafe Tasmania’s existing Work Health and Safety Advisory Service.
The SFT program was developed in consultation with the rural industry and is strongly supported by an industry-led stakeholder reference group. This work is gaining national attention for its approach to raising awareness of work health and safety in the rural sector.
The SFT program aims to reduce farm related death, injury and disease, and improve the health and safety of workers in the Tasmanian rural sector by:
* raising awareness of farm safety issues;
* encouraging discussions about safe farming;
* building leadership safety cultures and influencing attitudes;
* producing and disseminating targeted information; and
* working with industry stakeholders to provide training and education.

In the financial year to 30 June 2023, the SFT Program provided over 200 requests for guidance and advice. SFT is also collaborating with business partners to run a series of tractor safety awareness sessions throughout the State including King and Flinders Islands. Plans are well underway for this to occur.
Since the inception of the program to the end of March 2023, over 315 safety management plans have been developed for and with farmers, tailored to their individual farm operations. These safety management plans are critical to achieving safer farming practices and outcomes.
In addition, SFT has developed a 32-page practical guide aimed at farmers, family members, workers and contractors who operate quad-bikes. The guide is available on WorkSafe Tasmania’s website at GB321 Quad Bike Safety Guide (worksafe.tas.gov.au)

Update response provided by THS South 14 October 2022

Recommendation 1

Transfer of Care processes have been ratified and uploaded into SDMS.

Recommendation 2

The Statewide Separation Summary Policy has been adopted. All separation summaries are sent electronically by encrypted transmission or by Fax.  Separation summaries are also sent to the My Health Record where one exists.   The KPI is 48 hours.  GP Liaison Officer  receives and logs complaints where handover is inadequate.

Updated response provided by THS South 14 October 2022

Feedback is provided through existing case review within Medical Imaging

Response received from Southern Cross Care received 24 October 2017

In order to meet this recommendation, the following actions have been undertaken by the Management of SCCT across all of our nine RACF, including Yaraandoo.

Processes reviewed

• The initial assessment and subsequent reassessment of resident manual handling care needs.  There were found to be appropriate.
• The development and manual handling care plans and the re-evaluation of care plans as resident needs changed.  These were found to be appropriate.
• The processes used to ensure all staff were aware of the manual handling  needs of all residents.  These processes were found to be theoretically appropriate.
• Manual handing education program content - The content was amended. Please see below;

To determine the actual level of staff awareness and compliance with documented manual handling care plans an audit tool was developed and an audit of observed compliance against documented care interventions was undertaken at all RACF's including Yaraandoo.  This audit process demonstrated a compliance level of 85-98% across the RACF's.

The content of the manual handling education program provided by our external manual handling training provider (IPM) was amended to include a heightened emphasis on the care plan; the importance of adhering to the care plan and the actions to take if the care plan interventions were not effective or appropriate for a resident.

The manual handling teams at each RACF were also provided with additional training to assist them to be more confident in initiating immediate action when poor practice was identified.

Following the roll out of the revised education program a further audit was undertaken.  This audit involved assessing 100% of residents at all RACFs for compliance against manual handling care plan directives.  The results of this audit showed a compliance level of greater than 98% at all RACFs.

The audit will be repeated at least quarterly in all SCCT RACFs.  A compliance rate of lower than 95% will require  additional education and audting to be undertaken until an appropriate score is consistently achieved.

Response from Department of Primary Industries, Parks, Water and Environment received 26 March 2018.

Recommendation 1

1.1 The Solicitor General provided legal advice that, as it stands the PWS does not have the power to stop people walking on tracks.  The PWS will consider possible amendments to the National Parks and Reserved Land Regulations 2009 in 2019.  The  PWS must consider the full implications of any changes.

1.2 PWS visitor services and field staff have been encouraged to have conversations addressing safety concerns when encountering any visitors looking dangerously ill-prepared for the local walking conditions and recommend that under-prepared walkers do not depart.  Walkers can no longer arrive, book and depart on the same day.  Online bookings must be made at least 24 hours prior to planned departure.  Walking fees are refunded to walkers who decide not to proceed.

Recommendation 2

Website

2.1 Overland Track - Walk Safely and Warnings (about the weather) have been updated on the PWS website.  These are in line with messages given in other States.  A summary of the Walk Safely Information is provided in English and translated into Mandarin, Japanese and Indonesian.

2.2 The Walker Safety Checklist now contains a minimum gear checklist with photos of items listed (and a space for signing) a comprehensive gear checklist; top 10 tips for packing in a very easy to understand 'illustrated walker' in cartoon style, translated into four languages; and "Looking after your feet' contains footwear advice and photos of the different types of track.

2.3 Online bookings must be made at least 24 hours prior to planned departure.

2.4 A new PWS website is currently under development.  The brief to designers includes a requirement for a 'translate to other languages' button.  Translation of every HTML web page will be possible, however not PDF documents.

2.5 Communications plan: Commerical operators and key stakeholders are to be alerted once all measures are in place.  A communications plan will be implemented to ensure key stakeholders are aware of the walker safety initiatives.

Recommendation 3.

3.1 Welcome signage outside key visitor sites has QR codes  on them, (Cradle Mountain, Mt Field, Freycinet and Narawntapu).  These QR codes link to the PWS website where there are park brochures translated into four languages.  These are Mandarin, Traditional Chinese, Indonesian and Japanese.  The park brochures have standard safety messages included.

3.2 Walker safety banner: Two banners showing the 'illustrated walker' have been placed beside the Overland Track visitor reception desks at the Cradle Mountain Visitor Centre.  One is English and one is in Mandarin.

3.3 Beautiful one day, deadly the next: These large permanent signs are to be erected outside the Visitor Centre at Ronny Creek and Dove Lake, in Englsh and Mandarin.  Photos contrast fine weather with blizzard conditions.  There are being manufactured and are due for installation in March 2018.

3.4 A Walker safety video highlighting key safety messages has been developed.  It will be promoted via social media platforms and at the Cradle Mountain Visitor Centre.  It warns people of dramatic and rapid weather changes, with a backdrop of Cradle Mountain in sunshine and later under snow.  It carries a strong verbal message and visuals reminding visitors to carry warm and waterproof clothing.

3.5 Social media: Various walker safety social media posts have occurred using the tagline 'Beautiful one day.  Deadly the next.'

3.6 An emergency 'Apple' shelter has been installed at the Cirque on the Cradle plateau, in  the vicinity of where Kang Jin perished.

3.7 Staff: Mandarn speaking 'bilingual' Discovery Rangers have been employed from Boxing Day until the end of January for the last three summers at Cradle Mountain, Mt Field and Freycinet.  During key tourist periods, Mandarin speaking Visitor Services Officers have been employed at Cradle Mountain, Mt Field and Freycinet Visitor Centre's to ensure safety messages are imparted to visitors.

Response provided by THS South 14 October 2022

Immediately following this event, Royal Hobart Hospital Medical Emergency Response (MET and Code Blue) Protocol was updated to include the following:
Triggers for immediate contact with ICU Senior Registrar/Consultant and Home unit consultant
*             Admission to ICU is required
*             ICU/MED Reg at MET call unsure of diagnosis and appropriate treatment to provide
*             Difference of opinion between members of the MET regarding  
assessment/treatment
*             2 MET calls on the same patient with a 24-hour period
Other issues for Med Reg and ICU Reg to consider -
Can the patient remain on this ward/unit?
*             Can this ward manage high O2 or certain medications/infusions?
*             Does this patient require ECG monitoring & or telemetry?
*             Is the nursing & JMO capability supported?
Role guidelines & patient presentation/ vital signs/Investigation results criteria for immediate ICU consult/referral for Junior staff
Further the Standard 8 -  Recognising & Responding to Deterioration – Clinical Case Review Subcommittee was established – membership included Consultants form various specialties to review cases that flag patients who trigger a more in-depth case review.  Triggers include
*Unplanned admission to ICU,
*Change of Goals of Care at a MET call
*Death at a MET call
*>1 MET call in same admission
*Other Serious concern or adverse event
Standard 8 Chair is currently an Intensivist Consultant with a significant proportion of the Committee members being medical consultants  
The RHH also implemented a standalone Obstetric Emergency Response (OER) and the Code Newborn to compliment the Code Blue /MET for adult & Paediatric calls.

Updated response provided by THS South 14 October 2022

(a)  Microbiology Telephone Protocol developed and implemented requiring positive staph results to be phoned through directly to relevant clinician. Time, date and person receiving call is recorded.

(b) The Statewide Separation Summary Policy has been adopted. All separation summaries are sent electronically by encrypted transmission or by Fax.  Separation summaries are also sent to the My Health Record where one exists.   The KPI is 48 hours.  GP Liaison Officer receives and logs complaints where handover is inadequate.

(c) There has been a significant increase in FTE to match increased activity in ED and EMU.  EMU has a dedicated Consultant who rounds a number of times each day to facilitate appropriate discharges.