McManus, Vaughn Ross - Non-inquest findings

Contributing factors

• Lack of adequate warning signage at falls entrance and site
• No viewing platform or barriers to prevent dangerous access
• Absence of mobile phone telecommunication coverage
• Limited satellite phone availability and mobility
• Alcohol intoxication (blood alcohol 0.09)
• Methylamphetamine toxicity at potentially lethal level
• Wet slippery rock surface
• Unfamiliarity with location and lack of local knowledge
• Remote location with difficult terrain and long distance to emergency services
• Onset of nightfall delaying recovery operations

Coroner's recommendations

1. Improve and increase warning signage at Roaring Meg Falls entrance and along walking track regarding dangers of standing close to fast-flowing water
2. Install additional clear and visible signage alerting visitors to the culturally sensitive nature of the area and the preferences of Kuku Yalanji traditional owners
3. Install emergency communication infrastructure such as remote telephone stations (similar to Telstra stations present elsewhere on CREB track) proximate to Roaring Meg Falls
4. Ensure mobile satellite phone coverage is available and accessible to emergency responders and visitors in the area
5. Raise public awareness among non-indigenous visitors about cultural significance of the area to Kuku Yalanji people
6. Encourage visitors to consult with local police or traditional owners prior to attending Roaring Meg Falls
7. Facilitate interagency collaboration and roundtable discussions in consultation with Kuku Yalanji people to prevent similar deaths and optimise emergency response
8. Consider installation of viewing platform and/or safety barriers (acknowledging environmental and cultural constraints during wet season)