Record of Investigation into Death (Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11  
These findings have been de-identified by direction of the Coroner pursuant to S.57(1)(c) of  Coroners Act 1995 

I, Glenn Hay, Coroner, having investigated the death of

‘An elderly gentleman’



(a) That the ‘deceased’ aged 80 years died on 14 May 2010 at the Royal Hobart Hospital (RHH).

(b) The ‘deceased’ was a widow and under the care of medical practitioners at the RHH at the time of his death.

(c) The ‘deceased’ died as a consequence of multiple organ failure due to ischaemic heart disease and chest and abdominal injuries following a fall from a roof.

Circumstances surrounding the Death:

‘Mr E’ was described by his family as being independent, self sufficient and stubborn.

During the afternoon of 7 May 2010, ‘Mr E’ was at his home residence at Lindisfarne when he had an unwitnessed fall from his roof.

At 3.30pm Mr Hankin, a pedestrian passing ‘Mr E’s’ address noticed ‘Mr E’ lying on the concrete footpath inside the front yard of the property. Mr Hankin could see a ladder leaning and leading up to the roof of the single storey residence and a rake coming out of the chimney. From all the available evidence it is likely ‘Mr E’ had gone onto the roof in an attempt to fix a rattling metal chimney flue and had fallen a minimum of three metres. Mr Hankin immediately telephoned for an ambulance.

Ambulance personnel attended the residence. ‘Mr E’ was found conscious and in some pain. He was not overtly distressed. He was able to recall the sequence of events leading up to, during and after his fall. He denied any head, neck or back pain, or any loss of consciousness. ‘Mr E’ stated that he attempted to ‘break’ his fall with his right arm.

Due to the potential for serious injuries resulting from a fall at such height, Intensive Care Paramedic assistance was called. ‘Mr E’ was transported to Royal Hobart Hospital.

Upon examination at the RHH ‘Mr E’ was noted to have a GCS score of 15. He had both rib and pelvic fractures. He developed respiratory problems and required intubation and ventilation. He continued to bleed into the pelvis and had problems with his respiratory function complicated by his pre-existing emphysema. He had two cardio-respiratory arrests and deteriorated. He developed multiple organ, liver, renal respiratory and progressive cardiac failure. He developed an acute abdomen thought to be due to ischaemic bowel damage. On 14 May 2010 at 2.20am ‘Mr E’ died.

A post mortem examination was conducted by Forensic Pathologist, Doctor Christopher Lawrence. Dr Lawrence determined that the cause of ‘Mr E’s’ death was as a consequence of multiple organ failure due to ischaemic heart disease and chest and abdominal injuries following a fall from a roof.

Dr Lawrence made the following comments in relation to the deceased:

Autopsy confirms the presence of severe ischaemic heart disease and the injuries described. There is significant bleeding into the pelvis which has been an ongoing problem. There is also quite bad chronic obstructive lung disease due to emphysema due to his previous smoking. He appears to have developed pneumonia as well as the multiple organ failure. Ultimately his cardiac output was poor and his colon was clearly perfused and he developed what appears to be early ischaemia. Death appears to be due to a combination of his ischaemic heart disease and the injuries’.

Toxicology testing of a post mortem blood sample was unremarkable, indicating that medication probably played no part in the fall.

Comments and Other Findings:

I find ‘Mr E’ moved the ladder from his backyard and placed it against the roof of his home in the vicinity of the chimney and commenced climbing up the ladder toward the roof area most probably to inspect a metal flue in the top of the chimney. As there is evidence of a rake protruding from the chimney and ‘Mr E’ stating to a witness ‘I was just trying to get the flue cap off", I find that he was on the roof at the time when he fell to the ground, receiving injuries requiring his hospitalisation.

There is no evidence before me, to suggest the ladder caused the fall, or ‘Mr E’ had a medical event which caused him to fall to the ground.

I find this unfortunate fall contributed to the untimely death of ‘Mr E’ seven days later in hospital. His pre-existing conditions of high blood pressure and emphysema coupled with his age may well have made the task of climbing a ladder and a roof a more difficult and dangerous task compared to a younger and medically more fit person. However, I am not able to make a specific finding that a decline in physical capacity played a part in ‘Mr E’s’ death. Generally with age there is a loss of strength and agility. A decline in physical capabilities may also play a part in the higher proportion of deaths in the older age group.

I am satisfied that a full and detailed investigation has been undertaken in relation to the death of ‘Mr E’ and that there are no suspicious circumstances.

The deceased’s unfortunate death is an example of deaths occurring to individuals working in and around the home undertaking general maintenance. I must again warn home owners and others undertaking tasks not in the work/employment environment of the inherent risks attached, especially when working at height when lack of experience, lack of provision of proper safety equipment, lack of planned risk assessment, age or medical condition may give rise to dangers and risk to life.

It is again timely to warn members of our community about the risks and I adopt the comments of Coroner McTaggart in 2007 in a not dissimilar death when she said –

"Coronial files, particularly in other Australian jusrisdictions, disclose numerous examples of how such deaths occur in a variety of risk areas such as working on ladders or the roof, electrical work, garden maintenance and motor vehicle repairs.

As with the deceased, many of these cases involve what would, by reference to applicable Australian Standards, be considered unsafe systems of work or the use of unsafe equipment.

An Australian Standard is a set of guidelines produced as a result of deliberations by a committee of stakeholders in industry. In the context of particular equipment used in the workplace, an Australian Standard gives practical guidance for training and certification, and its safe selection, supply, erection and maintenance. A significant objective of an Australian Standard is the health and safety of persons engaged in industry.

Although Australian Standards have been primarily developed for the workplace, they represent best practice in safety generally. People involved in working on home maintenance should aim to follow these standards as closely as possible in order to minimise the risk of injury.

A high proportion of these deaths have occurred to males over the age of 60 years.

This older group of persons have not, for much of their working lives, been exposed to the pro-active culture of safety or risk management as it exists today. Instead the emphasis was more upon the "good sense" of the individual to take care. Since the Workplace Health and Safety Act 1995 was enacted the emphasis in the workplace and in training focuses upon assessment of risks and the elimination of those risks using all reasonably practicable measures. Workplace Standards Tasmania, a division of the Department of Justice, is charged with administering the Act and promoting health and safety in the workplace.

The deceased’s accident and other Coronial cases demonstrate that familiarity with a particular task is not necessarily good protection against the possibility of injury. In many situations the inadvertence triggering the injury or death is in itself borne out of familiarity and complacency."

Coronial statistics indicate deaths in the area of home maintenance in Tasmania have been uncommon in recent years.

However, this death should serve as a caution to those considering domestic maintenance work.

Based upon advice received from officers of Workplace Standards Tasmania in the course of this investigation, I would recommend that the following safety precautions are taken before embarking on domestic maintenance work:

  1. Take care to comply as far as possible with any Australian Standard applicable to the task at hand so as to reduce the risk of injury or death. Members of the public are encouraged to seek advice by telephoning the Workplace Standards Helpline on 1300 366 322. Copies of publications to assist with safety, such as use of ladders and working at heights, are available by request through the helpline or via the Workplace Standards website at
  2. Take regular breaks from the work. As a general rule a break of approximately 10 minutes every hour is advisable. This could vary depending on many factors such as age and physical make up. Many persons working on or around their homes are prone to work for long periods to achieve their desired objective. Regular breaks reduce the fatigue that may cause a loss of concentration. This precaution becomes more important for persons in the older age group.
  3. Realistically assess physical capability to perform the work. Consider whether any particular physical or mental limitations or disabilities may give rise to safety concerns or risk of injury in any given task. Review carefully whether the work can or should proceed safely in light of any such limitations.
  4. Conduct a risk assessment. That is, take time before commencing to identify potential safety hazards in the proposed work. It is important to also consider in this assessment the "worst case scenario" in respect of potential for injury. Steps should then be taken to minimise the risks of the occurrence of those events. In the event of uncertainty as to the best response to the risk, members of the public are welcome to contact Workplace Standards for assistance."  

I wish to conclude by conveying my sincere condolences to the family of the deceased. 

DATED: 23 December 2010 at Hobart in the State of Tasmania.


Glenn Alan Hay