RECORD OF INVESTIGATION INTO DEATH (WITHOUT INQUEST)
Coroners Act 1995
Coroners Rules 2006
I, Robert Pearce, Coroner, having investigated a death of
Leo Thomas COOPER-WHITE
WITHOUT HOLDING AN INQUEST
(a) The identity of the deceased is Leo Thomas Cooper-White born 7 June 1990, student.
(b) The cause of Mr Cooper-White’s death is fracture of the skull and a traumatic brain injury suffered in a fall.
(c) Mr Cooper-White died at about 1.30am on 18 March 2011 at Glen Dhu St in South Launceston.
(d) No other person contributed to the cause of his death.
1. Leo Cooper-White died on 18 March 2011. He was 20 years old. The investigation conducted on behalf of the coroner included identification and interview of witnesses by Tasmania Police, a post mortem examination conducted by a pathologist and toxicological analysis. The witnesses interviewed included the young men who were with Leo immediately before he died, and attending police officers.
2. The investigation discloses that Mr Cooper-White died from injuries suffered when he fell through the roof of one of the buildings at the Coats Patons complex in South Launceston.
3. The land I refer to as the Coats Patons complex extends from Thistle Street at the northern boundary along Glen Dhu Street to Heather Street at the southern boundary. It is a large area comprising about 10 hectares with what were formerly industrial buildings used as a textile mill which closed in 1997. For a period after that date the buildings were disused. Over the last 10 years or so the buildings have again come into use for a variety of purposes. Some have been improved. Some have industrial or semi industrial uses but the buildings are in varied states of repair.
4. Entrance to the land from the northern end is via a lane off Thistle Street. The lane runs in a north south and divides the property. The land to the east of the laneway is known as 31-45 Thistle Street West, South Launceston. At the relevant time it was registered in the name Churches of Christ Tasmania commonly known as Door of Hope. Some of the buildings are used by the church for its church activities. Other areas are leased by the church for other purposes to others.
5. The more westerly section of the land is above the laneway. It is known as 45-47 Thistle Street West and is owned by Mark Trevor Gilpin.
6. The building into which Leo Cooper-White fell is situated on the land owned by Door of Hope immediately to the east, or lower side, of the laneway. The building is referred to as the “Old Boiler House”. At the relevant time it was leased to Northern Filter Services apparently for storage and light industrial use. The roof of the building is constructed of corrugated profile asbestos sheet. The floor of the building is concrete and the distance from the floor to the roof is 8-10 metres.
7. Not far from the Old Boiler House but across the laneway on the western side land owned by Mr Gilpin there is a disused water tower.
The events of 17-18 March 2011
8. Leo and 8 of his friends went out in Launceston on the evening of 17 March 2011. The friends were Damien Hurst, Blake Pinnington, Michael Mason, Dylan Saville, Brenton Neighbour, Jesse Simmons, Benjamin Glover and Mitchell Langley. They were drinking alcohol and left the Royal Oak Hotel some time after midnight. They decided to go to what some of them referred to as “the water tower at the Door of Hope”.
9. From where they were the distance to the tower is about 2.5 kms. It would have taken them at least 30 minutes or so to walk but they ran at least part of the way. When they arrived they gained access to the laneway through a hole in the wire mesh adjacent to the entrance gate off Thistle Street at the northern end.
10. Some of the boys had been there before. Mitchell Langley said it was his idea to go to the water tower because he had been there 3 times before, the first time in about April 2010 and that he usually gained access from Heather Street at the southern end. Dylan Saville had been there twice, once with his girlfriend in November 2010 when they climbed through the hole near the gate from Thistle Street. Benjamin Glover had been to the tower once before in early 2011 and climbed through the same hole. It is unclear which entity has ownership of the gate and the entrance driveway. However the water tower is on Mr Gilpin’s land just above the laneway about 50 m or so in from the gate.
11. The motivation to go to the tower was to sit and enjoy the view over the city. I would infer that there was also an element of risk and daring involved in climbing up and down the tower. However not much turns on that because all but two of the boys climbed up and after talking and smoking for about 10-20 minutes climbed back down again.
12. After climbing down from the tower the rest of the boys moved back towards the gate. Mitchell Langley, Dylan Saville, Benjamin Glover and Leo were last down. The police have, on behalf of the coroner, interviewed each of them about what then happened. While they were still on the tower Leo talked to them about going onto the roof of the building below. He mentioned that he had done it before with a person called Sam or ‘DZ’.
13. Benjamin Glover said he would go with him. Dylan Saville said that he did not want to because he wanted to go back into town. He started to walk towards the gate. Mitchell Langley said that he was last down from the tower and started walking towards the gate but saw Benjamin Glover and Leo run towards the roof. He followed them. He saw Leo step on to the roof first followed by Benjamin Glover. They walked over a couple of peaks. According to Benjamin, Leo said be careful because the roof is “a bit shitty”. He commented to Mitchell that he was glad that he had come too. He then turned and took a step. The corrugated asbestos panel onto which he stepped did not take his weight. It broke and Leo fell through.
14. At the time he saw Leo fall through the roof, Mitchell was standing at the apex of one of the roof sections behind the section where Benjamin and Leo were standing. He said the roof looked brittle.
15. Some of the young men ran to find Leo. He had fallen 8-10 metres on to the concrete floor inside the building. The police and ambulance were called. Attempts were made to resuscitate Leo but he died from his injuries.
16. The post mortem examination disclosed that he had suffered a large skull fracture from the left temporal bone towards the base and extending to the right side with intracranial haemorrhage and laceration of the brain. These injuries caused his death.
17. The roof that each of the witnesses refer to is shown in the photos produced during the investigation. At a point below the laneway not far from the tower is an area where the roof of one of the buildings, because of the topography, extends to a level that is not far above the entrance section to the adjacent building. It would have been a simple matter to step across from this entrance section onto the roof. Until a few days earlier, this entrance section was obstructed by weeds and blackberries which had been removed in preparation for some building works.
18. The photographs, and evidence from a Workplace Standards Inspector who visited the scene, show the hole in the roof through which Leo fell to be between the top and the second purling at the north west end of the building.
Comment and recommendation
19. At a relatively early stage of the investigation Mr Kim White, Leo’s father, wrote to the coroner expressing concern about the circumstances of his son’s death and requesting that a public inquest be held. Mr White’s concern is natural and understandable. His son’s death must be devastating for him and his family.
20. However I have decided not to conduct an inquest. It is not the function of a coroner under the Coroners Act 1995 to attribute moral or legal blame or responsibility for the death of a person. The coroner’s principal function is to investigate and find facts relevant to determining identity of a deceased person, when and where a death occurred, how a death occurred and the cause of death. A coroner must also find whether any other person contributed to the cause of death. The fact, once determined, speak for themselves.
21. In this case the investigation has sufficiently disclosed the identity of the deceased person, the time, place, the relevant circumstances concerning his death and the particulars needed to register the death under the Births, Deaths and Marriages Registration Act.
22. I not satisfied that another person contributed to Mr Cooper-White’s death.
23. It is open to a coroner to make comments or recommendations. That is usually done in cases which raise some issue of general public importance. Mr White, in his letter, refers to the safety of the site and criticises the owners, the Launceston City Council and Workplace Standards Tasmania for allowing the site to be used, particularly as a workplace. He refers to alleged breaches of the Australian Building Code and State and Federal legislation, and refers to the buildings as unsafe and run down with no asbestos register. There may or may not be merit in Mr White’s claims. It is unnecessary for me to determine. Those issues do not relate to the cause of Leo’s death. Leo’s presence at the site and on the roof of the building from which he fell did not arise from the use of that building for any purpose. Leo was a young man engaging in exuberant behaviour with friends. The risk he ran by climbing onto the roof of that construction was obvious. It was appreciated by at least one of the young men that was with him.
24. I have considered whether comment is required about whether more should have been done to prevent unauthorised entry. I am satisfied that the hole in the fence is not an issue of consequence. If the hole had not been there the young men would have climbed over the fence. The more pertinent question is access onto the roof, particularly when the construction of the buildings allowed ready access onto the roof at a point not far from the laneway. Again, the recent removal of vegetation that may have formed some form of barrier is of little relevance. It had apparently not deterred access to the roof on at least one earlier occasion. The Door of Hope Church Building Projects Officer, Mr Gardam, informed the investigating police officer that he was not aware of any “security breaches” prior to this incident. He correctly pointed out that the water tower, the principal reason for the presence of the young men on this night, is on the land owned by Mr Gilpin. More fencing has been now been erected which prevents access on to the roof. Signage has been placed to warn of asbestos and the brittle roof. In this case the usual danger posed by asbestos is not relevant. What is relevant is that the panels were brittle and did not support the weight of a person walking on them.
25. I do not consider that an inquest is likely to elicit any further information concerning the issues that I am required to determine.
26. In the circumstances of this case I make no further comment or formal recommendation.
I would conclude by conveying my sincere condolences to Mr Cooper-White’s family.
DATED: 15 May 2012 at Launceston in Tasmania