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 the name of the deceased and family at the direction of the Coroner pursuant to S.57(1)(c) of Coroners Act 1995.
I, Simon Cooper, Coroner, having investigated the death of Mr T
Find that:
a) The identity of the deceased was confirmed;
b) Mr T died in the circumstances outlined further in this finding;
c) Mr T died as a result of suffocation due to compressive force on his chest;
d) Mr T died in December 2013 in North-West Tasmania;
e) Mr T was born in Victoria, Australia in 1977, was aged 36 years, was in a defacto relationship and was a small engine mechanic at the date of his death; and
f) No person contributed to the cause of Mr T's death.
Background:
Mr T was employed in North-West Tasmania at the date of his death. Mr T was born in Victoria in 1977 and was the youngest of three children.
Mr T was living in a defacto relationship with Ms D. They had two children. Mr T also had another child from a previous relationship.
Mr T was visually impaired but notwithstanding this was able to work productively throughout his adult life. His partner describes him as someone who appeared to her to suffer from depression but who would not seek any treatment or assistance for that condition.
In September 2011 he apparently attempted suicide by ingesting a significant quantity of paracetamol and alcohol. As a consequence he was admitted to a psychiatric clinic as an involuntary patient.
There is no history of Mr T receiving any treatment (other than the period referred to above as an inpatient) for depression or any other mental illness. It would seem that other than seeking assistance in relation to his visual impairment Mr T rarely consulted with, or sought treatment from, any medical practitioners.
Circumstances Surrounding the Death:
At about 11.00pm on 11 December 2013, Mr T's body was discovered by his partner crushed underneath a car in the garage of their home. Mr T had been working on the brakes of the car. His partner described him as someone who knew his way "around cars and engines" and that he had "been tinkering with cars for years". He had started working on the car that night at about 8.00pm. At about 9:30pm his partner reports he came into the house for a drink and they discussed the job he was doing on the car. He said he was nearly finished and would be up shortly. There was nothing about his demeanour that suggested to his partner that he was anything other than his normal self.
When his partner realised that Mr T had been longer than normal she went to the garage where she found his body underneath the car.
His partner immediately notified the Tasmanian Ambulance Service by telephone. Ambulance officers attended within 10 minutes. They in turn notified both the Fire Service and Police.
Upon their arrival ambulance personnel were met by his partner. She showed them to the garage where they saw a Ford sedan with Mr T lying face down trapped under it. A hydraulic trolley jack was seen under the car. One ambulance officer used the trolley jack to lift the car off Mr T's body which in turn allowed another ambulance officer to pull him out from under the car. Mr T was checked for signs of life but found to be deceased.
Police arrived shortly after the ambulance officers. A coronial investigation was commenced. Officers from the Criminal Investigation Branch and Forensic Services both attended the scene along with uniform personnel. The scene was carefully inspected and photographs were taken. The trolley jack was taken possession of for later examination. Officers located several car (or 'jack') stands near the vehicle. Car stands are devices used to support the weight of a vehicle on a jack. None of the stands were being used in this manner.
After identification at the scene, Mr T's body was removed and transported to the Launceston General Hospital where an autopsy was carried out by forensic pathologist Dr Ruchira Fernando. Dr Fernando found, and I accept her opinion, that the cause of Mr T's death was suffocation due to compressive forces on his upper torso.
Samples were taken from his body at autopsy and forwarded to the laboratory of Forensic Science Service Tasmania for analysis. Those samples did not reveal the presence of alcohol or any drugs in Mr T's body at the time of his death.
The trolley jack was subsequently examined by Mr Dale Marshall of Hydralink, Devonport. Mr Marshall is highly experienced in all aspects of the use, maintenance and storage of hydraulic jacks. I accept his expertise in this area. Mr Marshall in a report to me indicated that it was his opinion that the jack had suffered no hydraulic or mechanical failure. Mr Marshall said that for its age the jack was in a reasonable working condition. Mr Marshall made the point that the jack is a lifting device and it is not designed with any mechanical lock or safety device. Jack stands are required to be used in conjunction with such a lifting device. On this occasion they were not.
The most likely scenario in my view (and I find accordingly) is that, perhaps due to fatigue, Mr T, whilst working under the car, operated the jack in the wrong way which caused the vehicle to collapse on top of him and crush him. There no evidence to suggest the involvement of any other party. There is nothing either to suggest that Mr T's death was anything other than accidental. In reaching this conclusion I do not overlook his history in September 2011 however his behaviour on the day of his death seems to have been entirely normal and certainly he gave no indication whatsoever of any suicidal ideation or intention. There are no suspicious circumstances surrounding the death. I do note however that his death would have been avoided had he been using jack stands as well as the trolley jack.
Recommendations and Comments:
Section 28 (2) of the Coroners Act 1995 provides:
"A coroner must, whenever appropriate, make recommendations with respect to ways of preventing further deaths and on any other matter that the coroner considers appropriate."
In this case I am satisfied that Mr T would not have died if he had used jack stands in addition to the trolley jack. Since 2008 a mandatory national standard has been in force with respect to the manufacture of trolley jacks. In the main the standard deals with manufacture and design issues but relevantly requires that all trolley jacks carry safety markings including the following:
"The jack must be used only on hard level surfaces and be free to roll during lifting and lowering. Do not get under a vehicle that is supported by a trolley jack - use support stands". [EMPHASIS ADDED]
The reason for the requirement for a trolley jack to carry a warning against getting under the vehicle only supported by a trolley jack is the inherent danger associated with such an activity. As I have already pointed out if Mr T had utilised support stands (and several were located very close to his vehicle in the garage) then even if the jack collapsed he would have been protected from the falling vehicle.
I recommend that no person at any time work underneath a car or any piece of machinery supported only by a trolley jack.
In conclusion I wish to convey my sincere condolences to the family of Mr T.
Dated : 6 April 2015 at Hobart in the State of Tasmania.