Inquest into the death of Wilfried and Gisela Thor

Contributing factors

• Unacclimatised to extreme heat (travelled from winter climate)
• Temperatures reached 39.9°C on day of death
• Inadequate trail marking - orange arrow obscured by long grass
• Boundary fence down due to flooding two weeks prior
• Warning sign on fence missing due to flooding damage
• Minimal water carrying (600mL bottle)
• Mrs Thor not wearing hat
• No mobile phone or Wi-Fi reception in area
• Impaired decision-making from heat stress and dehydration
• Rocky terrain reflecting heat
• Lack of shelter
• Low humidity conditions
• Warm nights preventing cooling

Coroner's recommendations

1. Department of Tourism and Culture should advise visitors to parks in areas without telecommunication reception of the existence of GPS applications and their use when visiting those areas
2. Place signs after flow events warning that boundary fences may be damaged or missing
3. Place emergency fencing materials on high ground near boundary fence for quick repair without vehicular access
4. Place signage on trees across creek to mark park boundary where fence may be compromised
5. Implement directional signage for Gorge walk (anti-clockwise direction preferred)
6. Clear grass near trail entrances to improve visibility of orange markers
7. Install signposts near creek bed edge noting entrance to trails
8. Implement Emergency Response Procedure requiring all potential incidents to be reported immediately and action taken when vehicles are located with possible missing persons
9. Launch safety campaigns (Beat the Heat) at tourism information centres, car hire companies and accommodation providers
10. Provide specific safety messaging on signage across all Nature Parks
11. Consider personal locator beacons as supplementary safety tool