NSWother

Parsons final findings doc

Deceased

Michael Parsons

Demographics

male

Date of death

2008-08-25

Finding date

2012-04-20

Cause of death

Cardiac arrhythmia secondary to cardiac sensitisation from acute exposure to Bostik 9913 solvent containing toluene

AI-generated summary

Michael Parsons, a qualified shipwright employed by Seawind Catamarans for 7 years, died on 25 August 2008 after acute inhalation of Bostik 9913 solvent vapours while cleaning the interior of a catamaran hull at Bellambi factory, NSW. He was found unconscious with his head, torso and arms inside a storage locker containing solvent-soaked rags. Toxicological analysis confirmed death from cardiac arrhythmia secondary to cardiac sensitisation caused by toluene. The coroner found Mr Parsons was performing work-related cleaning duties. Critical workplace safety failures included: inadequate ventilation (only small cooling fans, no extraction), lack of chemical hazard training, ineffective respirator enforcement, and absence of material safety data sheet education. The coroner found the death preventable through proper safety systems and recommended improved safety alerts, updated safety data sheets warning of cardiac arrhythmia risk, and medical professional training on adrenaline administration in toluene toxicity cases.

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

Specialties

toxicology paramedicine

Error types

system

Drugs involved

bostik 9913 acetone toluene

Clinical conditions

toluene toxicity cardiac arrhythmia acute solvent exposure

Contributing factors

Inadequate ventilation in confined workspace; only small box cooling fans used, no extraction ventilation
High concentration of volatile toluene vapours in confined storage locker
Lack of worker training and education about serious health risks of solvent exposure, including death
Ineffective enforcement of personal protective equipment requirements, particularly respirators
Material Safety Data Sheets inadequately communicated; workers unaware of cardiac arrhythmia and death risks
Absence of comprehensive workplace risk assessment and chemical control measures
Inadequate supervision and management failure to address known solvent inhalation culture
Failure to escalate earlier incidents of solvent exposure to senior management
Metal storage containers with no lids; continuous evaporation of toxic fumes
No system to regulate amount of solvent taken or to restrict access to containers

Coroner's recommendations

WorkCover Authority to issue Safety Alert advising relevant industry that effects of inhalation or exposure to high concentrations of Bostik 9913 can include unconsciousness, cardiac arrhythmia and death
WorkCover Authority to issue Safety Alert to manufacturer Bostik Products and Plastics and Chemicals Industry Association advising that Material Safety Data Sheets should include in clear language that exposure to high concentrations of these chemicals can cause unconsciousness, cardiac arrhythmia and death
Copy of findings and expert reports (Professor Whyte toxicology report and Occupational Hygiene Report by Phillip Cantrell) to be provided to Bostik Australia Pty Ltd and Plastics and Chemicals Industry Association for consideration of amending Safety Data Sheets
Department of Health to consider issuing information, advice, education and training to ambulance officers and other medical professionals on dangers of administering adrenaline to patients suffering from acute toluene toxicity
Copy of findings and expert reports to be provided to Department of Health to assist in responding to recommendations regarding adrenaline administration

Full text

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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.

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