Inquest into the death of Terence Gray
Deceased
Terence Gray
Demographics
54y, male
Date of death
2020-01-04
Finding date
2021-10-22
Cause of death
Multiple injuries from collision with motor vehicle
AI-generated summary
Terence Gray, a 54-year-old man with chronic alcohol abuse and depression, was removed from a train at Grafton by a Passenger Services Supervisor (Mr Beadman) who lacked required authorization. The supervisor cited Mr Gray's alleged intoxication and ticketing issues, despite NSW Trains policy prohibiting removal for ticketing alone. Police, unaware of their statutory powers and the supervisor's lack of authority, took Mr Gray into custody and transported him 6 km to an isolated truck stop on a 100 km/h highway at 9:23 pm. Mr Gray was significantly intoxicated (estimated BAC 0.22-0.24), with impaired judgment and balance. He left the truck stop, entered the dark unlit highway, and was struck by a vehicle at approximately 10 pm, sustaining fatal injuries. Police failed to recognize Mr Gray's vulnerability or anticipate he would hitchhike on the highway. Key failures: Beadman's unauthorized removal decision without de-escalation; police's inadequate risk assessment of an intoxicated person in a dangerous environment; and lack of communication between agencies about statutory powers and appropriate alternatives.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Unauthorized removal of passenger from train by unaccredited Passenger Services Supervisor
- Failure to de-escalate situation or consider alternatives
- Police lack of awareness of statutory powers under Passenger Transport Act
- Inadequate risk assessment of intoxicated person in dangerous environment
- Placement of significantly intoxicated person at isolated location on unlit highway
- Lack of communication between NSW Trains staff and police about circumstances and alternatives
- Failure to recognize history of self-harm as risk factor
- Inadequate training of train staff in removal procedures
- Police assumption Mr Gray would remain at truck stop rather than enter highway
- Significant alcohol intoxication (estimated BAC 0.22-0.24) impairing judgment and balance
Coroner's recommendations
- Consider developing aligned policies, training or guidance material to ensure that in areas not within the Police Transport Command locations, both NSW Trains and NSW Police Force have a common understanding about: The powers that NSW Trains staff and NSW Police Force officers can exercise to require a person to leave a train; The effect of NSW Trains policy as to the circumstances in which such powers will be exercised by NSW Trains staff; The circumstances in which NSW Trains will request police assistance to remove a person from a train; The desirability of NSW Trains staff and NSW Police Force Officers discussing the circumstances in which a person has been asked to be removed from a train, including any alternatives that are available, including the passenger remaining or reboarding the train; The preferred train stations at which such passengers should be disembarked, in light of the location, the time of day, the availability of services or amenities and the circumstances of the person
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