Record of Investigation Into Death (Without Inquest)

Corners Act 1995
Coroners Rules 2006
Rule 11

I, Simon Cooper, Coroner, having investigated the death of Mr G

Find that:

(a) The identity of the deceased is Mr G;

(b) Mr G died as a result of a traumatic closed head injury following a 3 metre fall from a ladder;

(c) Mr G died on 1 October 2013 at the Royal Hobart Hospital, (‘the RHH’) in Hobart, Tasmania;

(d) Mr G was born in NSW and was aged 76 years, married, and a retired Postmaster at the time of his death; and

(e) No other person contributed to Mr G’s death.

Circumstances Surrounding the Death:

Mr G was an active, healthy and fit man up until his death. He had been married for nearly 46 years and was the father of 2 sons, and the grandfather to 4 grandchildren. Most of his working life was as a Postal Manager with Australia Post, from which he retired in 1996. He was also very active throughout his life in Rotary.

Mr G died from injuries he sustained in a fall from a ladder he was using at his home in southern  Tasmania, while carrying out routine maintenance. The fall happened in the morning of 1 October 2013 and he died in the RHH later in the evening of the same day.

Mr G’s death was the subject of a comprehensive and detailed investigation. That investigation reveals, and I find, that at about 10.00 am Mr G and his son went outside to fix guttering on the roof. Mr G placed an extendable ladder up against the side of the house near the house’s back door. He and his son argued as to who it was that would go up the ladder.  Mr G insisted that he would go up and actually physically pushed his son out of the way.  A short time after the job started the son saw his father fall down whilst still holding onto the ladder. Both the ladder and Mr G landed on the ground with Mr G lying on his back and the ladder partially on top of him; he was still after his fall holding the ladder with his right hand.

His son, an intensive care nurse, immediately went to Mr G and performed emergency first aid upon him. He conducted a spinal and airway assessment and called for an ambulance. Mr G's Son described seeing blood coming from his mouth and left ear as well as a large lump on the left side of his head.  He removed his father’s false teeth and did a jaw thrust in an attempt to clear his airway as well as checking his pulse, pupils and performing a sternal rub. Mr G was initially responsive to his name being called but stopped responding.

Mr G’s son held his father’s head and maintained his airway until arrival of the ambulance which then transported Mr G to the RHH where, given his injuries, he was treated with palliative care only in the RHH’s Intensive Care Unit. This continued until he was declared dead at 7.55pm that evening.

I am satisfied that the treatment afforded to Mr G by his son at the scene was of the highest possible order and the treatment he received at the RHH entirely appropriate. Indeed nothing more could have been done for Mr G in the circumstances.

Subsequent to his death an autopsy was undertaken at the direction of the coroner. That autopsy led pathologist, Dr Donald Ritchey, to express the opinion that Mr G cause of death was a closed traumatic head injury following a fall from a ladder. I accept this conclusion. An examination of his medical records revealed there was no medical condition which may have caused or contributed to his fall from the ladder; and a toxicological examination of his blood revealed no substances, drugs or alcohol, in his body which similarly may have had a causative effect.

The investigation conducted on behalf of this office by Tasmania Police leads to a conclusion that when Mr G ascended the ladder it was not secured in any way (at either top or bottom) nor footed by anyone. I conclude that the most likely cause of Mr G’s  fall was that he lost his balance and fell whilst still holding the ladder. That fall occasioned the head injuries which caused his death. It is very likely that the ladder been ‘footed’ or properly secured by being tied off at the top then he would not have had fallen in my view.

The circumstances surrounding Mr G’s death bear a remarkable similarity to those of Mr H, the subject of a finding published at the same time as this. Both Mr H and Mr G were at the time of their deaths 76 years of age. Both died as a direct consequence of falls from a ladder being used in both cases for routine home maintenance tasks. In both cases the ladder was not properly secure.   

Comments and Recommendations:

Section 28 of the Coroners Act 1995 provides:

“28. Findings, &c., of coroner investigating a death

1. A coroner investigating a death must find, if possible –

(a) the identity of the deceased; and
(b) how death occurred; and
(c) the cause of death; and
(d) when and where death occurred; and
(e) the particulars needed to register the death under the Births, Deaths and Marriages Registration Act 1999; and
(f) the identity of any person who contributed to the cause of death.

2. 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.

3. A coroner may comment on any matter connected with the death including public health or safety or the administration of justice.”

The findings required to be made pursuant to section 28 (1) are set out at the beginning of this finding. I have reached the view that the circumstances of both Mr G’s and Mr H’s deaths  require me to make both recommendations and comments pursuant to section 28 of the Coroners Act 1995.

Both of these deaths arose in remarkably similar circumstances, that is to say, falls by elderly men from ladders whilst both men were engaged in relatively routine household maintenance tasks.

Information recorded by the National Coronial Information System reveals that a total of 276 deaths resulting from falls from ladders were the subject of coronial notification in Australia between 1 January 2001 and 31 December 2012. The vast majority of these fatalities occurred in a domestic (or non- industrial) situation and almost all involved older males.

In Victoria alone 82 deaths were identified as a result of falls from ladders between 2000 and 2011. In a finding in relation to the death of a Mervyn Barry Maslin (whose death actually resulted from a fall in Penguin, Tasmania), Coroner Jamieson, of the Victoria Coroner’s Court, observed that of those 82 deaths:

• most involve persons over the age of 65;
• almost all of those persons were men;
• most were engaged in home maintenance activities; and
• while the ladder related injury (and death) rate is increasing in relation to incidents in homes it is stable in the work related context.

Many deaths arising from the use of ladders for home maintenance have resulted in recommendations and comments from coroners. In Tasmania there have been three reported coronial findings since 2007 in relation to deaths which occurred in remarkably similar circumstances. Each of those deaths, like those of Mr H and Mr G were, aside from being unfortunate, entirely avoidable and further examples of deaths occurring to individuals, usually men, working in and around their home undertaking general maintenance and utilising ladders in the course of that work.

In a finding delivered on 1 February 2007 Coroner McTaggart observed in that case, along with many of these cases, the systems of work and equipment being utilised would, by reference to applicable Australian Standards, be considered unsafe. That is, in my respectful view, precisely the case in both of the deaths the subject of my investigation here.

Coroner McTaggart went on to observe:

“An Australian Standard is 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 the 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.”

In addition to Australian Standards, a Code of Practice ‘Managing the Risks of Falls at Workplaces’ has been approved under section 274 of the Work Health and Safety Act 2012. The Code commenced on 1 January 2013 and although obviously not in place at the time of Mr H’s death it was when Mr G died.  As is the case with Australian Standards, the Code of Practice (as its title suggests) deals with how to manage the risk of falls in the workplace. It is said to be “a practical guide to achieving the standards of health, safety and welfare required under the Work Health and Safety Act and the Work Health and Safety Regulations”.  As is the case with Australian Standards, the Code of Practice represents industry best practice.  The Code is a comprehensive document and of course its applicability to the home environment is not mandatory. But the point is not whether it is mandatory – it sets out a variety of practices to manage the risk of falls, the utilisation of fall prevention devices, work positioning systems, and fall arrest systems, and should be followed absent very good reason not to do so.

In the context of this case the Code of Practice deals also comprehensively with the use of ladders.  Particularly relevant to Mr G’s death, the subject of this finding is the following:

‘Any ladder used in the workplace must be set up on a solid and stable surface, and set up so as to prevent the ladder from slipping. Single and extension ladders may be prevented from slipping by … securing ladders at the top or bottom, or if necessary, at both ends.’

The Code of Practice also emphasises the safe use of ladders by ensuring that the ladder is in good condition, that it is set up on firm, stable and level ground, that it is the correct height for the task to avoid reaching or stretching, and that three points of contact to the ladder are to be maintained at all times, and any tools are to be operated with one hand.

In my view the Code of Practice, and the guidance and recommendations it contains, is directly applicable to the use of ladders around the home for maintenance and the like. The Code should be followed.

I recommend that the following basic safety precautions are taken when using a ladder at home:

1. Take care to comply as far as possible with either the Australian Standard applicable to the task at hand or the Code of Practice approved under section 274 for the Work Health Safety Act 2012;
2. Ensure the ladder is in good condition and set up on firm and stable ground;
3. Ensure that the ladder is positioned so that it is neither too far from, nor too close to, the support structure;
4. Always ensure when using a ladder that it is secured either by being properly ‘footed’ by another person or tied off at the top (or both); and
5. Only ever undertake light work while on the ladder – and then ensure that three (3) points of contact with the ladder are maintained at all times.

In addition, it is quite clear as Coroner Jamieson observed in Maslin that while rates of deaths from ladders in the work environment remain relatively stable, they are increasing appreciably in a home maintenance context. 

Accordingly, I recommend further that the appropriate authority within government devise and deliver an advertising campaign warning of the risks of ladder use in the home maintenance environment, directed towards men aged 65 years and over, and providing basic strategies to minimise the risk of falls and consequent death from ladder use. Such a campaign should include, but not be limited to, making the community aware of the existence of both the applicable Australian Standard and the Code of Practice.

I conclude this matter by conveying my sincere condolences to Mr G’s family.

DATED:  22 August 2014   at Hobart in the state of Tasmania.    


Simon Cooper