1. Bulk Tanker Emergency Response-sharing lessons and improving outcomes Case Law – learning from the Coroner Dr Jane Hendtlass B.Sc.(Hons.), LL.B.(Hons.), Ph.D., A.R.A.C.I., F.A.I.C.D., A.I.M.M. 6 September 2012

2. Outline The Role of the Coroner The Role of the Coroner Relevant Legislation Relevant Legislation Coronial Investigation Coronial Investigation Tankers in the Coroners Court Tankers in the Coroners Court Cause of the collisions resulting in driver deaths Cause of the collisions resulting in driver deaths Comments and Recommendations Comments and Recommendations Summary Summary

3. Role of a Coroner The coronial system of Victoria plays an important role in Victorian society. That role involves the independent investigation of deaths for the purpose of finding the causes of those deaths and to contribute to the reduction of the number of preventable deaths and the promotion of public health and safety and the administration of justice. Coroners Act 2008

4. Relevant Legislation All coroners ’ work is directed by legislation including : All coroners ’ work is directed by legislation including :  Coroners Act 2008  Victorian Institute of Forensic Medicine Act 1985  Police Regulation Act 1958  Births Deaths & Marriages Registration Act 1996  Human Tissue Act 1982

5. Coroners Act 2008 Creates the Coroners Court of Victoria as an inquisitorial jurisdiction Creates the Coroners Court of Victoria as an inquisitorial jurisdiction Provides for appointment of coroners Provides for appointment of coroners  Lawyers with five years experience Includes 8 full time coroners: Includes 8 full time coroners:  State Coroner and Deputy State Coroner  Direct appointments  Magistrates allocated in consultation with the Chief Magistrate  Magistrates in regions who also sit as coroners

6. Victorian Institute of Forensic Medicine Act 1985 The functions of the Institute include: The functions of the Institute include: o to provide facilities and staff for the conduct of examinations in relation to deaths investigated under the Coroners Act 2008. o to provide reports to coroners about the medical causes of deaths and the findings and results of investigations and examinations.  to host the National Coroners Information Service

7. Police Regulation Act 1958 Assumes that police investigators provide corners with crucial specialist assistance in that it: Assumes that police investigators provide corners with crucial specialist assistance in that it: o Requires police to assist the Coroner whenever a coroner so requests. o Provides for police allocation to the Police Coronial Support Unit. o Enables police assistance in Inquests.

8. Human Tissue Act 1982 The coronial role takes precedence over retrieval of human tissue for transplant or research: The coronial role takes precedence over retrieval of human tissue for transplant or research: o A coroner must also give consent to taking of tissue from deceased donors if the death is or may be a reportable death. o Authority under the Coroners Act 2008 to remove tissue is, subject to any order to the contrary by a coroner, authority for the use, for therapeutic, medical or scientific purposes, of tissue removed from the body of the deceased person for the purpose of the post-mortem examination.

9. Summary Role of a coroner is to investigate reportable deaths Role of a coroner is to investigate reportable deaths Doctors, forensic pathologists, police, the Registrar of Births Deaths & Marriages and the general public must assist a coroner investigating a reportable death Doctors, forensic pathologists, police, the Registrar of Births Deaths & Marriages and the general public must assist a coroner investigating a reportable death A coroner must authorise removal of tissue from donor if the death is a reportable death. A coroner must authorise removal of tissue from donor if the death is a reportable death.

10. Coronial Investigation The Coroners Act 2008 requires a Coroner to investigate all reportable deaths to determine where possible: The Coroners Act 2008 requires a Coroner to investigate all reportable deaths to determine where possible: o identity, o time and place of death, o cause of death.  Unless the death is from ‘ natural causes ’ or further investigation is not in the public interest, the Coroner must also determine: o how the death occurred.

11. National Coronial Information Service All deaths reported to coroners in Australia & New Zealand All deaths reported to coroners in Australia & New Zealand o Not all the same selection criteria o Coding varies Includes autopsy and toxicology reports, Form 83s, Findings, Recommendations Includes autopsy and toxicology reports, Form 83s, Findings, Recommendations Board includes all State Coroners and Chief Coroners Board includes all State Coroners and Chief Coroners Access is by consent of the Board Access is by consent of the Board

12. Tankers in the Coroners Court 104 deaths involving “ tankers ” reported to coroners in Australia since 2001 or about 10 deaths a year 104 deaths involving “ tankers ” reported to coroners in Australia since 2001 or about 10 deaths a yearincludes 3 multiple death incidents including the Pettet family in Koo Wee Rup in 2001 3 multiple death incidents including the Pettet family in Koo Wee Rup in 2001 26 tanker drivers or occupants 26 tanker drivers or occupants

13. Tanker Occupants in the Coroners Court The 26 tanker drivers or occupants include: 15 tanker drivers in Victoria 15 tanker drivers in Victoria 6 tanker drivers interstate 6 tanker drivers interstate 4 tanker passengers 4 tanker passengers 1 tanker passengers interstate 1 tanker passengers interstate

14. Tanker drivers in the Coroners Court The cause of death for the 31 tanker drivers include: 5 injuries sustained in the incident 5 injuries sustained in the incident 9 natural causes including: cardiac condition, undiagnosed brain tumor, aortic dissection 9 natural causes including: cardiac condition, undiagnosed brain tumor, aortic dissection 2 suicide when not in truck (does not include suicide by other road users) 2 suicide when not in truck (does not include suicide by other road users) 4 drugs 4 drugs

15. Cause of the collisions resulting in tanker driver deaths Maintenance: Maintenance: o Break in the diesel line o Non standard parts Driving: Driving: o 7 roll over consistent with o 6 speed in the circumstances 2 no seat belt 2 no seat belt 1 possible fatigue 1 possible fatigue Fire following roll over following cardiac event Fire following roll over following cardiac event

16. Cause of the collisions resulting in other road user deaths Tanker driver Tanker driver o 2 fail to stop: 1 explained by hypoglycaemia Passenger Passenger o In sleeper compartment without restraint o Fell out of truck Other road user Other road user o 5 fail to stop or give way at intersection o 9 lost control or keep proper look out o 5 possible suicide o 3 pedestrian on road o 1 pedestrian behind tanker

17. Comments and Recommendations A coroner may make recommendations to any Minister, public statutory authority or entity on any matter connected with a death which the coroner has investigated, including recommendations relating to public health and safety or the administration of justice. A coroner may make recommendations to any Minister, public statutory authority or entity on any matter connected with a death which the coroner has investigated, including recommendations relating to public health and safety or the administration of justice. If a public statutory authority or entity receives recommendations made by the coroner, the public statutory authority or entity must provide a written response, not later than 3 months after the date of receipt of the recommendations. Coroners Act 2008 If a public statutory authority or entity receives recommendations made by the coroner, the public statutory authority or entity must provide a written response, not later than 3 months after the date of receipt of the recommendations. Coroners Act 2008

18. Recommendations include: All employers in the transport industry should be encouraged to be involved in the “ Health Break ” program and insuring, as far as is practicable and appropriate, that their drivers participate in the checks and any follow-up examinations and treatment: findings in the death of Robin Alan Scott & Rodney Thomas Gesler All employers in the transport industry should be encouraged to be involved in the “ Health Break ” program and insuring, as far as is practicable and appropriate, that their drivers participate in the checks and any follow-up examinations and treatment: findings in the death of Robin Alan Scott & Rodney Thomas Gesler

19. Recommendations 2 include: I would recommend that publicity be given to warning of the dangers of fitting after market parts unless they possess the same or equivalent properties of the part they are replacing.

20. Summary 1. Coroners only see incidents in which someone dies. 2. Coroners investigate tanker incidents with the assistance of the forensic pathologist, the police and other experts. 3. There are about 10 deaths per year arising from tanker incidents in Australia. 4. About 3 tanker drivers die a year. 5. Half of all driver deaths are from natural causes. 6. All roll over deaths occurred because drivers lost control during a health related event, mainly cardiac disease or drug- related speed.