Record of Investigation Into Death (Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Timothy John HILL, Coroner, having investigated the death of Vaughan Matthew BEER

I have decided not to hold an inquest into the death because the investigation into the death has sufficiently disclosed the identity of the deceased person, the time, place, cause of death, relevant circumstances concerning the death and the particulars needed to register the death under the Births, Deaths and Marriages Registration Act.

Having conducted an investigation I do not consider that the holding of an inquest would elicit any information further to that disclosed by the enquiries conducted.

Find That :

(a) Vaughan Matthew Beer died on or about the 11 November 2010 on the Murchison Highway, Somerset;

(b) Mr Beer was born on the 19/01/1972 and was aged 38 years.

(c) he died following a two vehicle motor vehicle crash;

(d) the cause of his death was multiple trauma consistent with a motor vehicle crash.

Circumstances Surrounding the Death :

Mr Beer was an asthmatic and suffered from periodic stomach problems that would cause him to vomit during the night. He had also suffered stomach ulcers in the past. In 2009 he broke his ankle and developed a severe infection which resulted in him suffering from blood clots. Mr Beer was under medication for the clots. He was also part of the methadone program after he had become addicted to pain killers following a back injury. There is evidence that he was a heavy cannabis user and smoked it every day to assist with pain relief. There is some evidence that in 2009 Mr Beer had threatened to take his own life.

On the evening of the 10 November 2010 Mr Beer went to bed complaining he did not feel well. He had a troubled night and did not sleep well. His partner indicated that he was still ill in the morning and remained in bed when the family left for work and school.

At about 9.50am on the morning of the 11 November Mr Adam Saward arrived at Agrifert in Somerset. He was driving an Isuzu truck. The truck was loaded with fertiliser for delivery to an address in Elliott.

At about 11.20am Mr Paul McGuire saw Mr Beer driving a red Ford Laser north on the Murchison Highway. Mr McGuire reported that Mr Beerfs head was lying almost at right angles to his left shoulder and that he 'looked out of it'. He indicates that Mr Beer's face and head was shiny and it appeared to be covered in sweat. Mr McGuire waved at Mr Beer but got no response. He estimated that Mr Beer was travelling at approximately 90 km/hr.

A short time later the vehicle being driven by Mr Beer veered into the incorrect lane after negotiating a curve in the road. Mr Saward reported that Mr Beer was slumped across to the left. Mr Saward manoeuvred his truck into the North bound lane hoping that the Ford Laser would pass to the left and avoid a collision. As the two vehicles approached each other Mr Saward braked hard causing his truck tyres to skid. Mr Beer suddenly looked up and appeared to be about to swing on the steering wheel when the two vehicles collided.

The Ford impacted heavily with the left corner of the Isuzu truck. Mr Beer died at the scene from injuries received from the crash.

The vehicles involved in the crash were examined by Transport Inspectors. Both vehicles were considered to be mechanically sound and roadworthy prior to the crash and no faults were identified that could have caused or contributed to the crash.

A post mortem examination conducted by Dr Brain (Pathologist) found that Mr Beer died as a result of multiple trauma consistent with a motor vehicle crash.

Toxicology testing revealed evidence of methadone and cannabis. Both these drugs in combination are likely to enhance the adverse effects associated with the drugs taken alone and have the potential to impair driving performance.

The Murchison Highway where the crash occurred was in good order. The weather conditions at the time of the crash were fine although it was cloudy. Visibility was considered good.

An investigation into the circumstances surrounding the death of Mr Beer was conducted by Tasmania Police. The investigating officer concluded that the cause of the crash can be attributed to the inattentive driving of Mr Beer. No blame was attributed to the driver of the Isuzu Truck, Mr Saward who attempted to avoid the collision.

Comments & Recommendations :

I am satisfied, based on the evidence of Dr Brain that Mr Beer died as a result of multiple trauma consistent with a motor vehicle crash.

Mr Beer had been ill the night before the crash and it is evident that he had very little sleep. On the day of the crash he was driving with a combination of cannabis and methadone in his system. Both drugs would have impaired his driving performance.

I find that the combination of the drugs and his fatigue caused Mr Beer to either fall asleep or become drowsy to the point he was unaware of what was occurring on the roadway. These circumstances led to Mr Beer colliding with the Isuzu truck and losing his life.

This case again reminds us of the dangers of driving whilst fatigued and/or when affected by drugs.

I find that Mr Saward took all reasonable steps to avoid the collision.

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

This matter is now concluded

DATED : 8 December 2011 at Launceston in the state of Tasmania


Timothy John HILL