Coronial findings (decisions) 2021

Response from Tasmania Parks and Wildlife Service  11 August 2022

• Signage has been installed at the entrance to Sandy Cape Track (Temma) and the Arthur Beach Track (Gardiner Point, Arthur River): Sand Flags Recommended.
• Quick release adaptors for sand flags were attached to all operational vehicles in the Field Centre likely to operate on the track.
• Sand flags are stored for easy access/attachment when field centre vehicles are accessing the tracks.
• The PWS Arthur River Visitor Centre is trialling selling sand flags to the public.
• The APCA Recreational Driving Guide, available to all Recreational Driver Pass holders, already contained advice to install sand flags under Vehicle Checklist (page 7, point 7).

Response from Tasmania Health Service Statewide and Mental Health Services received 8 March 2022.

A recent meeting with the Director of Nursin at the King Island Health service and Senior Nursing staff of the North West Regional Hospital clarified the process surrounding the discharge of patients from Spencer Clinic Inpatient Ward to King Island.

• Patients should not be discharged from Spencer Clinic on Fridays to travel to King Island on the same day.
• Prior to discharge an appointment with the GP is to be made at a time asap after the patient returns to King Island.
• During weekdays in business hours, transport can be arranged for the patient to be picked up at the airport and returned home if friends/relatives are unavailable.  Spencer Clinic will need to liaise with the King Island Heath Services to arrange.
• The relevant Medical Officer in Spencer Clinic will contact the King Island GP as soon as practicable to advise of the patients discharge date from Spencer Clinic.
• The discharge summary or interim essential clinical details will be sent to the GP advising discharge date, appointment time with GP, discharge medications and legal status
• The relevant Medical Officer will write the discharge appointment in the DMR as King Island Health Services can access these details.

Response from  De Bruyn's Transport 23 July 2022

Recommendation 1: Rollover Awareness and Training

De Bruyn’s Transport continues to utilise the VicRoads Heavy Vehicle Rollover Prevention Program and, specifically, its dynamic load elements as the cornerstone of our induction training for all employees and not just those involved in harvest fish operations. The reason for this is quite straightforward and that is that every employee has some role to play in reducing the likelihood of rollovers and incidents more broadly. We then focus on specific rollover awareness factors during both our mentoring as well as our refresh programs. We have also engaged the service of a Driver Trainer to provide additional coaching to all our drivers. This includes a combination of in cab assistance, review/follow-up of telematic data and ongoing focus on travel times for higher risk activities.

Recommendation 2: SOP Guidance

Our Safe Operating Procedure for this specific task along with our Risk Register and our weather related guidance were all updated some time ago. These updates then influence our mentoring and internal checking efforts, especially when it comes to conducting safety observations and reviewing travel times and probation.

Recommendation 3: Probationary Review

Safety assessments of driver performance not only occur at the end of probation but are undertaken on an ongoing basis. We often utilise telematic data for this process as well as timesheet reviews, camera evidence and even road user and customer anecdotal feedback. We already have a mentoring process for new drivers as well as those undertaking new tasks and, as mentioned above, we plan to use our recently employed Driver Trainer to provide even further coaching and safety feedback to our drivers.

Recommendation 4: Refresh Training

Our three yearly refresh program already includes specific rollover awareness elements. Our intention now is to broaden this process by utilising our recently recruited Driver Trainer to provide programmed in cab refresh sessions and assessments (similar, in many respects, to what pilots undertake now).

Response received from the Department of Natural Resources and Environment Tasmania 13 July 2023

in response to the coronial recommendation NRE Tas took steps to update the 'Fishing Safety' page on the Fishing Tasmania website to highlight dangers of rock fishing and included a link to Royal Life Saving Australia site which provides further information about staying safe while rock fishing wearing a life jacket.

Update provided by THS South 14 October 2022

Since the Coroner’s recommendation a Mental Health Short Stay Unit has been implemented to improve flow for mental health patients out of the ED.
With the ED redevelopment, planning is underway to include a secure high acuity area for mental health patients as well as a calming, private area for lower acuity patients where they are able to wait for their assessment separate from non-mental health patients.

Response from  Derwent Valley Council 30 August 2022

Following is report of actions taken by the Derwent Valley Council to reduce risks to motorists on the gravel section of Glenfern Road.

Council’s Operations Manager, a qualified engineer, was charged with investigating improvements to the road.  He developed a scope of works and issued a Request for Quotation to civil contractors in December 2020 with the following overview of works required:

The unsealed section of Glenfern Road has a higher than average incidence of casualty crashes including a fatality in recent years. Derwent Valley Council has identified a number of sections at which sight distance could be improved via vegetation reduction and sight benching / reducing the slope of cut batters.  The extent of works is over a length of approximately 2.1km of Glenfern Road.  There are six sections, each of approximately 50m long identified for sight benching on the eastern side of the road. There are also a series of sections totalling approx. 600m that require vegetation removal.

A grant from the Department of State Growth Safer Rural Road Program was secured on 23 March 2021 for:

Vegetation reduction, site benching works, installation of guard rails and signage at Glenfern Road.

Works were completed and reported to the grant program on 30 June 2021.

All proposed sight benching, vegetation reduction and guard rail was successfully achieved as per application submission except for the length of guard rail marked in location below. This was attempted but unfortunately was not achievable due to presence of shallow rock.

With the reduced scale of the guard rail installation and favourable rates for the benching and vegetation reduction, the total cost requested from the grantor is $80,086.42