Ms D - Non-inquest findings
Deceased
Ms D
Demographics
47y, female
Date of death
2016-02-13
Finding date
2016-11-01
Cause of death
Cardiorespiratory failure precipitated by multiple rib fractures rendering the chest wall incapable of effectively expanding the lungs and oxygenating the blood
AI-generated summary
Ms D, aged 47, was struck and killed by a motor vehicle at a public park on 13 February 2016. The vehicle rolled downhill after the owner engaged only a partially effective handbrake (at the 6th ratchet position instead of the 7th) and left the automatic transmission in neutral rather than Park. Mechanical inspection found the handbrake required engagement at the 7th ratchet for full effectiveness. The coroner concluded this death was preventable had the driver either fully engaged the handbrake or placed the transmission in Park—both standard vehicle security practices. This case highlights the importance of understanding vehicle safety mechanisms and the limitations of relying on a single restraint system, particularly on slopes.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- Handbrake engaged only partially (at 6th ratchet instead of 7th)
- Automatic transmission left in neutral instead of Park
- Vehicle parked on a slope
- Driver reliance on handbrake alone without securing transmission
Coroner's recommendations
- The coroner noted that this tragic incident would have been prevented if the driver had engaged the handbrake into the seventh ratchet setting or higher, and/or placed the automatic transmission in Park
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