Coroners Act 1995
Coroners Regulations 1996
Regulation 14
Form 4

I, Stephen Raymond Carey, Coroner, having investigated the death of

“the deceased”



(the deceased) died sometime between approximately 7.00pm on the 6th July 2005 and 9.00am on the 7th July 2005 at Kings Pier Marina, Hobart.

“the deceased” 58 years old at the time of his death. He was a self-employed painting contractor and had been in a de-facto relationship.

I find that the deceased died as a result of drowning.

At the time of the deceased’s death he was not being treated by a medical practitioner.


He had in the past had his driver’s licence suspended on a number of occasions due to offences of drink driving. Following his last such suspension he decided not to regain his driver’s licence. In the course of his business he relied upon a friend, to drive him about. At approximately 10.00am on the 6th July 2005, Mr T collected the deceased from his home and conveyed him to various locations about Hobart in order that the deceased could provide work quotations. Between about 12.30pm and 3.00pm they were at two licensed establishments during which time the deceased drank beer and gambled on race-horses.

They then left with the intention that the deceased would be taken to his home. However during that journey the deceased received a call on his mobile telephone from “a friend” and arrangements were made for him to meet “Ms E” and three of her female friends. The deceased was thereupon conveyed to the Customs House Hotel arriving there shortly after 3.00pm. The deceased remained at Customs House Hotel from that time until approximately 7.00pm during which time he drank alcohol in company with “Ms E”, her female friends and Mr S who was also known to the deceased.

The group left the hotel at various times leading up to 7.00pm with the females walking to another licensed premises nearby, Mr S walking to a bus stop at Franklin Square and the deceased engaging a taxi. The deceased entered the taxi at approximately 7.00pm carrying a bag of ice that he had purchased at Customs House Hotel. Initially the deceased expressed a desire to be returned to his home in order that he could get a key and then return to his yacht which was moored at Kings Pier Marina. He then changed his mind and asked to be taken directly to Kings Pier. He was taken to the gate at the end of that pier, the taxi driver, Mr M, offered to take the deceased to his home or to Tasport control building to obtain a key to the gate which was locked. The deceased refused and alighted from the taxi. Mr M then drove to the TasPort’s building and control tower area to see if there was any indication of how he might obtain a key to the Kings Pier Marina. This took about 5 minutes, he was not successful and when he drove back past the Kings Pier he noted the deceased was not in sight.

In the meantime the deceased’s partner had returned home at about 4.45pm that day from a business trip to the north of the state. At 5.42pm she missed a call to her mobile telephone from the deceased’s mobile telephone. Her attempts to contact the deceased on his mobile phone from then until approximately 8.00pm were unsuccessful with the calls going to his message bank. She concluded that he had probably gone to stay on his yacht which was something he had done on previous occasions. On Thursday morning (7 July 2005) upon realising the deceased had not returned home she went to Kings Pier and boarded his yacht. She noted the bag of ice on the bow of the boat but observed that nothing was out of place on the yacht which was not consistent with the deceased having been on board. She called the supervisor of the deceased’s business and learnt that there had been no contact with the deceased that day. “His partner” then arranged for “Mr T” to attend the area and make some enquiries. At the conclusion of those enquiries and after a discussion between “his partner” and Mr T they contacted the Police as they now expected the deceased may have fallen into the water.

The Police attended and the deceased’s body was located partly submerged under the jetty of the marina adjacent to “his yacht”. The post-mortem that was conducted not only showed clear evidence that the deceased had drowned but also determined his blood alcohol reading at 0.270 g/100ml.


I am satisfied based upon the investigation conducted by Tasmania Police that there are no suspicious circumstances and that the deceased’s death was as a result of an accident. Although the precise mechanism will not be able to be determined it is probable that after throwing or placing the bag of ice on the bow of “his yacht” the deceased has fallen into the water when attempting to climb aboard. This accident has most likely occurred some time between 7.00pm and 8.00pm on that evening. “His yacht” was moored bow first to the marina jetty and in order to board, it was necessary to pull on a bow mooring rope, bringing the bow close enough to the marina to allow a person to step aboard. The degree of difficulty of this task would be dependant upon a number of factors including the tide level, stability of the vessel and the co-ordination and agility of the person boarding the vessel. It is clearly an unwise, if not dangerous, procedure for someone who was significantly affected by alcohol. The degree of impairment of the deceased is best described by the taxi driver, Mr M, who when he collected the deceased from Customs House Hotel says he was:

“..very drunk and fell over or stumbled back when he first tried to get into the cab”

This unfortunate and accidental death illustrates once again the dangers of combining excessive alcohol, boats and water.

Two particular issues that became apparent during the investigation require comment. Firstly is the continued sale of alcohol by staff at Customs House Hotel to the deceased despite the fact that the deceased would for a period of time at least have been significantly intoxicated. The deceased had a blood alcohol reading of .27% and yet the bar manager suggests that the deceased;

“..did not appear excessively intoxicated although it was always hard to tell how drunk the deceased was”.

This is not consistent with the description of someone having difficulty standing when trying to get into a taxi as described by “Mr M”. I do not accept that the signs of intoxication would not have been obvious to the bar staff at some stage during the approximate 4 hours that the deceased was drinking at Customs House Hotel. I suspect he was afforded some leniency as he was known to the staff as a regular customer, so much so, that the drinks he purchased were entered on an account provided by the hotel. Observation of the deceased together with knowledge of the number of drinks he had consumed ought to have indicated to staff that the deceased was significantly affected by alcohol. Section 78 of the Liquor Licensing Act 1990 provides an offence to serve someone who appears to be drunk. The dictionary meaning of “drunk” is an inability to properly control oneself due to alcohol or under the influence of alcohol. The description by the bar manager that the deceased did not appear “excessively intoxicated” and Mr S that the deceased “was intoxicated but not heavily” masked the fact that he was drunk. I recommend that the management of the Customs House Hotel and in fact all licensed premises examine the criteria they use in determining whether a patron is or is not “drunk” within the meaning of the legislation. In the interests of the individual and of society generally, the requirements of responsible service of alcohol must be honestly and properly applied.

The deceased did not have upon him a key to enter Kings Pier Marina when he arrived there. He appears that he has either climbed over the gate or someone has opened the gate for him. It became known from antedotal information that the deceased had on prior occasions climbed the gate to gain entry to the marina. The Port security officer on duty at the relevant time does not recall anything out of the ordinary occurring that evening. Presumably he would regard opening the gate for a person as unusual, he says he would have acted to detain any person who he observed climbed the gate. The evidence does not permit me to determine how the deceased entered the marina. No matter by what means the deceased gained entry he did have a legal right to be there. Even if someone had opened the gate for the deceased this would have been unlikely to have created a legal duty for them to further assist the deceased.

The TasPorts Authority advised that since the deceased’s death information had been provided to it from other marina tenants that the deceased was known to climb the marina gate. Prior knowledge is denied by that authority. The deceased was provided with a key to the gate as a tenant. The climbing of the gate, if this occurred, was a decision taken by the deceased when he was not in possession of his key, this act in itself was dangerous and is perhaps suggestive of the deceased’s inability to realise the risk he was taking going to his yacht that night in an intoxicated condition.

It has also been suggested that alterations required to be made of the mooring lines for “his yacht” may have been causative of or contributed to the deceased falling into the water. In approximately 1999 Mr Sexton fitted the mooring ropes to “his yacht” upon the request of the deceased. The result was that the vessel was moored with the bow to the marina jetty. Two bow ropes were fixed to the jetty at approximately 45 degrees on the port and starboard side. At the stern there were pylons on both sides of the vessel and stern ropes were fixed to both. Stringer lines were attached from those pylons to a point approximately mid ship on both port and starboard sides. These ropes were attached in such a way to accommodate the rise and fall of the tide. A final rope was attached from the bow and fastened directly to the marina jetty. The purpose of this middle bow line was to enable the vessel to be pulled as closely as possible to the jetty, in so doing pulling taut the stern and springer lines resulting in the vessel being able to be held stable for boarding. This centre bow line had been affixed to the guard rail on the opposite side of the jetty to where “his yacht” was moored, thereby laying across a walkway. In approximately May 2005 a representative of TasPorts contacted “his partner” advising that the centre bow line was creating a hazard to pedestrian traffic and required that it be removed. There is a dispute as to when the deceased or “his partner” may have first sought to have a cleat fitted to the jetty to allow this middle bow line to be safely secured but it is accepted that a formal request for the work to be done by TasPorts was made at this time in approximately May 2005. Although the work was scheduled to be carried out by TasPorts maintenance personnel it had not been done prior to the deceased’s death.

Given that I am unable to determine the precise mechanism of how the deceased fell into the water I am therefore unable to say to what extent the absence of the middle bow line caused or contributed to the fall. No doubt its absence would have made the vessel less stable when boarding. However the deceased I infer, was aware of the added difficulty the lack of the middle bow rope posed for boarding, but he proposed to board the vessel nonetheless. His lack of appreciation of the danger that may have been associated with this was no doubt due to his intoxicated state.

Before I conclude this matter, I wish to convey my sincere condolences to the family of the deceased. This matter is now concluded.

DATED This 20th day of October 2006

Stephen Carey