Coronial
ACTcommunity

Inquest into the death of Paul Edward Storey

Deceased

Paul Edward Storey

Demographics

71y, male

Coroner

Coroner K J Archer

Date of death

2022-01-24

Finding date

2026-03-20

Cause of death

Multiple injuries sustained in a cycling accident caused by impact with a tree branch

AI-generated summary

Paul Storey, a 71-year-old active cyclist, died from multiple injuries sustained when his head struck a large tree branch hanging across a bicycle path on Black Mountain Peninsula, ACT. A public report of the hazardous tree had been made via the Fix My Street portal 14 days before the accident, but was allocated to the wrong government department and not processed promptly. The coroner found a public safety issue arising from systemic failures in how the government triaged and responded to hazard reports. Had the report been correctly routed to the arborist team, the hazard would have been remediated on the same day, preventing this tragedy. The coroner emphasised that 48 hours was too long to address such an obvious and serious public safety risk.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Error types

systemcommunicationdelay

Clinical conditions

Multiple impact-related injuriesCervical and thoracic spine fracturesHyperextension injury

Contributing factors

  • Large tree branch hanging across bicycle path at head height
  • Fix My Street report (Case 151070) received 14 days prior but not processed
  • Report allocated to incorrect business unit (Place Management instead of Urban Treescapes)
  • Lack of integration between IT systems used by different government departments
  • Failure to manually redirect case after rejection in incorrect system
  • Inadequate risk assessment and triage procedures for hazard reports

Coroner's recommendations

  1. The Territory should consider publishing practical guidance as to how issues associated with Territory infrastructure that might cause serious injury or death are identified, assessed, and actioned based on risk assessment principles
Full text
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Source and disclaimer

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