Coronial
QLDother

Mapperson, Wayne George - Non-inquest findings

Deceased

Wayne George Mapperson

Demographics

58y, male

Coroner

McDougall

Date of death

2012-09-25

Finding date

2015-02-20

Cause of death

Multifocal bleed into brain (subarachnoid and subdural haemorrhage) from injuries sustained in a workplace fall

AI-generated summary

A 58-year-old truck driver and forklift operator died from a severe head injury sustained in a workplace fall on 29 August 2012. He fell while using an unsuitable, unsecured ladder to access a mezzanine storage area. The coroner identified several safety failures: use of an inappropriate ladder not designed for the task, lack of proper safety measures for working at heights, and the worker being alone during high-risk activities. While medical care at hospital was appropriate and timely, the delay in discovering the fall delayed treatment. The coroner could not definitively determine whether he fell from the ladder or mezzanine, or the precise cause of the fall. Despite serious concerns about workplace safety practices at the employer, criminal referral was not made due to insufficient evidence to prove unsafe work caused the specific injuries beyond reasonable doubt.

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

Specialties

trauma surgeryintensive careneurosurgeryemergency medicineoccupational and environmental health

Error types

systemprocedural

Clinical conditions

traumatic brain injurysubarachnoid haemorrhagesubdural haemorrhageskull fracturerib fractures

Contributing factors

  • Use of unsuitable ladder not designed for accessing mezzanine
  • Ladder not properly secured at base or top
  • Ladder not inspected or safety tested
  • Slippery floor recently painted
  • Inadequate space on mezzanine for safe movement
  • Worker engaged in high-risk activity while alone
  • Delay in discovering the fall
  • Lack of clear direction from management regarding safe work practices
  • Unclear cause of fall - may have been ladder slip, loss of balance on mezzanine, or syncope

Coroner's recommendations

  1. Referral to Office of Fair and Safe Work Queensland for consideration of whether AWL should have been charged with safety violations
  2. Emphasis on importance of trained first aiders in workplaces engaged in dangerous activities such as forklift operation and work at heights, with regular refresher training
  3. Necessity for employers to enforce safe work practices and not tolerate unsafe practices based on employee disposition
Full text
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Source and disclaimer

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