Inquest into the death of William Brown
Deceased
William Bernard Brown
Demographics
62y, male
Date of death
2014-06-12
Finding date
2016-04-21
Cause of death
respiratory failure secondary to high cervical cord injury (C3/4 and C7/T1 fractures with ligamentous disruption and cervical spinal cord oedema and haemorrhage)
AI-generated summary
William Bernard Brown, a healthy 62-year-old, died from respiratory failure secondary to cervical spinal cord injury after being struck by a falling branch from an African Mahogany tree at a golf course. Six days after the impact resulted in quadriplegia and respiratory compromise, he chose to cease treatment. The coroner found the tree was dangerous due to inadequate maintenance and management. No regular inspection or arborist-led assessment had occurred despite previous similar deaths from African Mahogany trees and known risks. The contractor who performed limited deadwood removal in March 2014 identified the tree as dangerous requiring further work but failed to communicate this to the property leaseholder. Inadequate lease terms between the City of Darwin and the golf course operator created ambiguity about tree maintenance responsibility, and neither party resolved this despite being aware of the risks. The coroner concluded the death was preventable with proper tree management and maintenance protocols.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- falling branch from African Mahogany tree located in high-traffic first tee area
- inadequate maintenance and inspection of the tree prior to incident
- no regular arborist assessment or management program
- ambiguous lease terms regarding tree maintenance responsibility between City of Darwin and Perry Park Pty Ltd
- failure of tree contractor to communicate identified safety concerns after work completed
- over-extended end-weighted branch with potential decay
- time-constrained maintenance work (5 hours) that did not allow proper tree assessment
- lack of protective measures for patrons in high-use area
Coroner's recommendations
- Compulsory inspection of all trees on property owned by City of Darwin at least every six (6) months
- Such compulsory inspections to be conducted by qualified arborists
- City of Darwin to conduct an audit of all current leases and ensure inclusion of: compulsory inspection of all trees at least every six (6) months by qualified arborist; and specific provision as to who bears responsibility for costs of inspections and/or works
- City of Darwin to ensure all future leases include: compulsory inspection of all trees at least every six (6) months; inspections conducted by qualified arborist; and specific provision regarding responsibility for costs of inspections and/or works
Further listening
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