Record of Investigation Into Death (Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

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

Glyn Edwin John



(a) Glyn Edwin John (Mr John) died on 8 September 2009 at the Royal Hobart Hospital in Tasmania, aged almost 88 years;

(b) Mr John was born in Porthcawl, Wales on 19 September 1921, and had lived in Australia for 60 years. He was married in 1946 and had five adult children, and was a retired builder;

(c) Mr John died as a result of head injuries sustained after falling from a ladder at his home.


Mr John moved to Australia with his wife Florence, in 1949. They moved to Gordon in the Channel area of southern Tasmania with their five children in 1986 where Mr John built the family home. Mr John retired from his occupation as a carpenter, builder and building manager in 1981. Mr John and his wife were still residing in that home at the time of his death.

Mr John had always been a fit and active person. About two years prior to his death, Mr John began to have dizzy spells resulting in having a pacemaker implanted. He had occasional incidents where he would become dizzy and feel unwell, and on several occasions had to lie down. On one other occasion he was taken to Calvary Hospital by ambulance where he was monitored and discharged the following day.

Mr John’s adult daughter, Bronwyn, lives in Kingston.


On the afternoon of Monday 7 September 2009 Mr John was at home with his wife and went outside to work on the roof of the gazebo which had become loose in strong wind.

It is clear from all available evidence that between 3:00pm and 3:28pm that day Mr John fell from a 1 metre ladder, striking his head on the concrete ground. The fall was unwitnessed; however, Mr John called to his wife who found him lying on his back on the floor of the gazebo, bleeding from an injury to the back of his head. At 3.28pm Mrs John called an ambulance and then covered Mr John with a blanket and put a pillow under his head.

At 3.32pm Tasmania Ambulance despatched an ambulance from the Kingston branch station as the ambulance and crew from the closer station at Huonville were on another case and unable to attend. The Kingston ambulance was despatched with only one officer, Officer Hampton. He was working by himself as there were no assisting volunteers available at the Kingston station.

The ambulance arrived at about 4:20pm at which time Mr John received medical attention. He was unable to get up due to feeling dizzy and having chest pain. Officer Hampton was highly suspicious of injury to the head and spine and radioed for back-up assistance at 4.33pm. It would seem that with some difficulty he managed to get Mr John onto a spine board with a cervical collar and was able to manoeuvre a stretcher nearby to Mr John because of the flat terrain in the backyard. He then dragged Mr John on the spine board for about two metres to the stretcher and with what I would consider to be significant difficulty, he was able to lever the board onto the stretcher in a see-saw motion and thus load Mr John into the ambulance and it left at 4.51pm for the Royal Hobart Hospital. During all of this Mr John was conscious and cooperative. Officer Hampton drove the ambulance and accordingly Mr John was without direct assistance.

The ambulance met with the second crew at 4:59pm, at which time a second paramedic was able to assist with the care of Mr John. En-route to Hobart and at about 5.10pm, Mr John unexpectedly vomited and lost consciousness, his condition deteriorating. Paramedics began airway care but were unable to intubate Mr John. As a third ambulance crew was required to assist drive ambulance and patient, they had to await that arrival at 5.51pm.

On arrival at the Royal Hobart Hospital, at about 6.35pm, Mr John was given further emergency care and was intubated. A CT scan revealed the extent of his head fractures, brain injuries and bleeding. His medical prognosis was poor and after discussions took place with Mr John’s family, a decision was made to not perform surgery. During the following evening Mr John was placed in palliative care and he passed away as a result of his injuries at 9:55am on 8 September 2011.

Findings & Comments: 

I am satisfied that a thorough and detailed investigation has occurred into the death of Mr John.

My investigation centered upon whether –

  • there were adequate ambulance facilities available in this case, and
  • there are adequate ambulance facilities available generally in isolated rural areas, and
  • whether the alleviation of an approximate 3 hour delay in Mr John arriving at RHH and difficulties in having him transferred into the ambulance may have resulted in a different outcome.

I find that Officer Hampton did an exceptional job in all of the circumstances especially when working alone and when he suspected significant head and/or spinal injuries. It must have been an extraordinary task to load Mr John into the ambulance on his own, whilst at the same time ensuring he received optimal care in a situation where movement should obviously be minimised.

I have received detailed written responses from Ambulance Tasmania (AT) in relation to my queries and others of a peripheral nature.

I accept that the current AT staffing model is tiered throughout Tasmania depending upon the case load and the relative isolation of some communities in the rural setting. Metropolitan crews have two salaried officers while outer urban crews have a mix of at least one Paramedic assisted by Volunteer Ambulance Officers on each day or night shift. In more remote or rural areas ambulances are crewed by volunteers only. Kingston is an outer urban station. I accept that this tiered model enables Tasmania to provide more response points per capita than elsewhere in Australia and in many cases were it not for this model, long response times would be experienced by the public more generally than in this case.

I accept that the spread of professional paramedics has increased in areas of Tasmania over the recent years however there is still a reliance on volunteers and where volunteer officers are not available qualified officers are dispatched with their ability to deliver advanced clinical skills in emergency or urgent requests for assistance to members of the public.

I find that there was nothing ‘out of the ordinary’ on this day except that Officer Hampton did not have a volunteer working with him on that shift, coupled with the tyranny of distance from other support or appropriate hospitalisation. Whilst this is not an ideal situation in a community with unlimited resources and funding, I accept that the policies and procedures and criteria published and adopted by TA are adequate in all of the circumstances. In the absence of unlimited community funding, the situation in which Mr John and Officer Hampton found themselves in on that day was unavoidable given that there was no volunteer support available and no other AT services were available to assist in a more timely fashion.

There is no evidence that Mr John’s condition, deterioration and death were at all affected by Officer Hampton responding alone. It is possible that had there been another officer to assist then the ambulance may have arrived at RHH in a more timely fashion; however I am unable to say whether this would have favoured Mr Johns’ survival owing to the severity of his head injury. Mr John had sustained a severe closed head injury the prognosis from which was unlikely to favour his survival.

Mr John’s unfortunate death is a further example of deaths occurring to individuals having arisen from 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. In this case I accept that Mr John was an experienced builder well used to working at height and no doubt had pride in his experience and abilities, however his age and medical condition were strong indicators of why he should not be doing so.

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

"Coronial files, particularly in other Australian jurisdictions, 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 conclude this matter by conveying my sincere condolences to the family of Mr John. 

DATED : 28 February 2011 at Hobart in Tasmania.


Glenn Hay