Coronial
QLDother

Moore, Geoffrey Grahame

Deceased

Geoffrey Grahame Moore

Demographics

51y, male

Date of death

2012-03-06

Finding date

2014-09-26

Cause of death

Massive head injuries due to quad bike accident

AI-generated summary

Geoffrey Moore, a 51-year-old maintenance supervisor, died from massive head injuries after crashing a quad bike into a fence at a feedlot. The quad bike had a corroded and seized throttle cable that caused excessive revving. A co-worker had reported the same throttle malfunction three days earlier. Key clinical and safety lessons include: the importance of systematic maintenance and fault-reporting systems; ensuring equipment is properly secured when faulty; mandatory use of helmets and personal protective equipment; and formal training in equipment operation. The preventability of this death hinged on timely repair of the known mechanical defect and proper use of safety equipment. The absence of a formal fault-recording system meant critical safety information was lost in verbal communication.

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

Error types

Drugs involved

Contributing factors

  • Corroded and seized throttle cable causing full throttle condition
  • Lack of formal system for recording equipment faults
  • Failure to secure faulty equipment (keys left in ignition)
  • Absence of formal training in quad bike operation and inspection
  • Non-use of helmet despite policy requirement
  • Insufficient maintenance scheduling (serviced 12 months apart instead of 6-monthly recommendation)
  • Heavy rain and wet conditions affecting visibility
  • Rear brake not fully adjusted, limiting stopping capability

Coroner's recommendations

  1. To be considered in second phase of multiple inquest
Full text

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