Coroners Act 1995

Coroners Regulations 1996
Regulation 14
Form 4

I, Olivia McTaggart, Coroner, having investigated the death of
“the deceased”


“the deceased”died in 2006 at the Royal Hobart Hospital, Liverpool Street, Hobart.

I find that “the deceased” died as a result of head and chest injuries which he received as a result of a fall from a scaffold.


“The deceased” was in the process of preparing a rear bedroom window for painting.

“The deceased” had placed two extension ladders against the rear wall of the house. On the rungs of each ladder were two metal brackets that housed upon them a wooden plank, which formed a scaffold. The plank extended out over the metal brackets at both ends. “The deceased” had used this ladder bracket scaffold set-up for many years when painting and doing other odd jobs around the outside of the house.

“The deceased” had been working on the scaffold for approximately two hours when his sister arrived. She went to the rear of the house to speak to him. At the same time his wife was speaking to her husband from a bedroom window inside the house.

His wife informed “the deceased” that some friends were coming over for a cup of tea and he replied “Good, that means I can knock off.” At this time “the deceased” looked down toward his sister who was talking to him. In doing so he stepped with his foot onto the overhang of the scaffold causing it to dislodge and tip over.

“The deceased” fell approximately three metres downward hitting the side of his head on a raised garden stone edging. He landed on his side wedged between the garden edging and the wall of the house. 

At the time of the fall “the deceased” was wearing a crash helmet, however it came off in the fall.

“The deceased” lost consciousness as a result of the fall. Attending ambulance officers were not able to revive him.

“Tthe deceased” was transported to the Royal Hobart Hospital where a short time later he was pronounced deceased.


After “the deceased’s” accident a police officer experienced in forensic investigation recreated the scaffold and photographed the scene.

The scaffold recreation was reviewed by inspectors of Workplace Standards Tasmania to determine its safety.

The safety issues identified by the inspectors with reference to applicable Australian Standards were as follows:

  1. The overhang of the scaffolding plank outside the ladder was excessive. An overlap of 200mm is considered acceptable practice in a workplace.
  2. The scaffolding plank did not fit properly in the metal brackets attached to the ladder. This allowed the potential for some movement creating instability.
  3. The support brackets for an acceptable ladder bracket scaffold should be “underslung” from the ladder with chains to allow for some minor adjustment and at the same time allowing the user access to the plank without having to climb over the bracket and plank when ascending or descending the ladder. “the deceased’s” scaffold was not in accordance with this design. In fact the plank and brackets were placed on the outside of the ladders causing a tripping hazard and easier access to the overhanging portion of the plank.
  4. The working platform for a ladder bracket scaffold should never be placed at a height where a person could fall more than 2 metres, unless there is perimeter protection. It is likely that “the deceased’s” scaffold was in excess of this height by about 700mm.
  5. One of the ladders used by “the deceased” did not have “feet” attached to it. This would make the ladder prone to slipping particularly on the concrete surface. Further, the concrete surface appears to fall away in the area where the ladders may have been placed, possibly creating a hazard.

In each of the above ways, “the deceased’s” scaffold did not comply with the applicable Australian Standard.

Having regard to all of the evidence obtained, I am satisfied that a significant cause of “the deceased’s” fall was the inappropriate set-up of the scaffold. The plank, with its extended overhang, was placed on the external side of the two ladders. In his attempt to either turn or to descend the ladder by climbing over the bracket, “the deceased” stepped on the excessive overhang causing the plank to pivot and lift and him to fall.

His own inadvertence, perhaps triggered by fatigue or the distraction of talking to others, also played a part in his stepping on the overhang.


“the deceased’s” unfortunate death is an example of deaths occurring to individuals working in and around the home undertaking general maintenance. 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 60years.

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.

Fatigue may have played a part in “the deceased’s” fall. He had been working on the scaffold for about 2 hours. The evidence suggests that he had not taken a break of any length for that period of time. 

I am not able to make a specific finding that a decline in physical capacity played a part in “the deceased’s” death. However, 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.

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. 

The file held by this office will now be closed. 

I wish to convey my sincere condolences to “the deceased’s” family. 

DATED: Thursday, 1 February 2007 at Hobart in the State of Tasmania.

Olivia McTaggart