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 H.

Find that:

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

 (b) Mr H died of a traumatic brain haemorrhage following a 2.5 metre fall from a ladder;

 (c) Mr H died on 25 November 2012 at the Launceston General Hospital, (the ‘LGH’) in Launceston, Tasmania;

 (d) Mr H was born in Austria in 1935, was 76 years old, married, and a semi-retired Metal Engineer at the time of his        death; and

 (e) No person contributed to the cause of Mr H’s death.

Circumstances Surrounding the Death:

Mr H lived at Legana and had done so for many years. He was described by his wife and other family members as being a fit and active man for his age. Mr H was married  for 45 years and fathered 3 children. He immigrated to Australia from Austria in 1958. Most of his working life was spent as a boiler maker welder from which he retired in 2000. Upon retirement he started running a part time wrought iron business (which Mrs H described as ‘more of a hobby’). Apart from open heart surgery in 2003 the evidence is that Mr H was in good health.

On 24 and 25 November 2012 he was doing some work upon the guttering, fascia and flashing on a shed which served as a workshop at his home. He seems to have completed that work without incident on 24 November with the assistance of a friend Mr P. Mr P describes fixing timbers to the shed in preparation for the fixing of new fascia and flashing. The work came to an end that day when both men realised they had the wrong type of screw. While carrying out that part of the job on that day a twin ‘A’ frame ladder with a plank of aluminium, in the nature of a scaffold, was used from which to work.

Mr P returned to, Legana with the correct screws at around 10.00 am the next morning.  Using an extension ladder Mr P secured timber along the length of the shed in preparation for the installation of the new fascia. Mr H stayed on the ground while this was done. After this part of the job was completed Mr P climbed onto the roof, to affix some iron. Mr P says that he asked Mr H whether he wished to use the A Frame twin ladder set up on the previous day. Mr H apparently declined indicating it was ‘too much hassle’ and that he was happy to stand on and work from a single metal extension ladder.

The two men then started affixing the iron to the already fitted timber. The process adopted involved Mr H moving a ladder to the side of the shed and then passing to Mr P a length of iron. Mr P screwed the length of iron to the timber. The ladder was apparently positioned such that it was underneath the fascia as it could not rest against it because it was to the fascia that the iron was being fitted.

The process was repeated several times. What is important to note is that the ladder on which Mr H was positioned and from which he was working was at no stage secured by either being ‘footed’ at its base by another person, nor tied off either at the top or bottom (or both).

When this part of the job was completed the fixing of flashing over the iron was started.  This involved the same procedure as that employed when affixing the iron i.e. Mr P on the roof and Mr H positioned on and working from an unsecured ladder. As this part of the job was being carried out Mr H’s daughter arrived at her father’s residence with her partner.

At about noon Mr H and Mr P returned to ground level to modify the next length of flashing. Both men then returned to the ladder and roof respectively. Again Mr H positioned the ladder so that its top was under the fascia. Once again it was neither ‘footed’ nor tied off. Mr H was using a cordless power drill to attach screws to the flashing.

While adjusting a screw with the cordless power drill in his right hand and at the same time attempting to push the flashing towards the shed (which meant both Mr H’s hands were engaged in carrying out the work and neither available to hold onto the ladder) he is reported by Mr P as losing balance and toppling backwards from the ladder with the flashing still in his hand. He landed straight on the back of his head and neck. The ladder remained standing upright.

Emergency services were contacted and personnel from Tasmania Police and Tasmanian Ambulance Service attended. CPR was commenced upon Mr H by Mr P, and continued for roughly 15 minutes, with the assistance of Angela and her partner until the arrival of Tasmanian Ambulance Service personnel. Although revived by the paramedics it was apparent that Mr H had sustained significant head injuries as a result of his fall.

He was transported by ambulance to the LGH where at about 4.00pm he died from the injuries sustained in that fall.

The circumstances of Mr H’s death were the subject of a comprehensive investigation, which included an autopsy that was carried out at the direction of the Coroner and careful consideration of the circumstances surrounding his fall by both offices of Tasmania Police and Workplace Standards. The latter attended but did not formally investigate Mr H’s death for it was concluded, appropriately, that his home was not a workplace in terms of the Workplace Health and Safety Act 1995.

As a result of the autopsy the pathologist concluded that the cause of Mr H’s death was ‘traumatic brain haemorrhage with intracerebral contusional haemorrhages, subarachnoid haemorrhage and left subdural haemorrhage following an accidental fall from a height’.  This conclusion as to Mr H’s cause of death is one that I accept in the circumstances of this case.

Samples taken at autopsy were subsequently analysed at Forensic Science Service Tasmania (FSST). Other than the presence of drugs consistent with Mr H’s admission to the LGH after his fall, no other drugs and no alcohol were detected in his body. The investigation surrounding Mr H’s death indicated that he was, at the time of his death, taking 2 prescription drug's perindopril and esomeprazole. Neither of these drugs were detected as being present in his body by FSST, but this is attributable to the fact that both drugs as compounds are ‘non-target analytes’ in the screening procedure used by FSST and therefore neither their presence nor absence is able to be confirmed. I am however satisfied that the ingestion or use of drugs had no part in Mr H’s fall from the ladder.

The investigation also revealed that, and I find, that when Mr H fell from the ladder he had only two (2) points of contact with that ladder. It is also quite clear that the ladder from which Mr H fell was not secured at either the top or the bottom in any way nor was it footed (that is to say, held) by any person whilst he was using it. Securing either at the top or the bottom, or by means of another person holding the ladder, are basic safety precautions that will prevent the ladder and any user overbalancing and falling from it. But most importantly Mr H did not maintain three (3) points of contact with the ladder at all times – another basic safety requirement.

The circumstances of Mr H’s death bear a remarkable similarity to those of Mr G, whose death is the subject of a finding published at the same time as this finding. Like Mr G, Mr H was also 76 years of age and died as a result of a fall from a ladder while carrying out routine maintenance at his home.

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 decision in a finding delivered on 1 February 2007 Coroner McTaggart observed in that case, along with many of these cases, the systems of work equipment being utilised would, by reference to applicable Australian Standards, be considered either unsafe systems of work or the use of unsafe equipment. 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 this 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 H’s family.


DATED:  3 September 2014   at Hobart in the state of Tasmania.    


Simon Cooper