Non-inquest findings into the death of Peter Raymond Thistleton

Contributing factors

• Fatigue and likely microsleep episode
• Undiagnosed and untreated sleep apnea
• Failure to wear seatbelt (fastened behind driver to disable sensors)
• Cannabis use (THC detected in blood)
• Evidence of habitual speeding
• Poor logbook compliance and inaccurate record-keeping
• Disrupted sleep due to untreated breathing difficulties
• Refusal to use prescribed CPAP device
• Self-medication with cannabis and Ventolin puffer instead of proper medical care
• Early morning driving at high fatigue risk (04:45 hours)

Coroner's recommendations

1. Introduction of driver monitoring devices (Guardian/Driver State Sensor systems) as compulsory equipment on all heavy vehicles; research showed 66-94% reduction in fatigue-related incidents
2. Mandated electronic logbook systems for heavy vehicle drivers to replace manual paper logbooks and prevent inaccurate/fabricated entries
3. Heavy vehicle drivers be provided education regarding dangers of sleep deficits and poor health whilst driving
4. Mandated use of tamper-proof front, side and rear vehicle recording cameras on all heavy vehicles
5. Mandated compliance monitoring systems for fatigue management regulations
6. Regular health screening for occupational drivers, including sleep disorder assessment and enforcement of treatment compliance
7. Workplace Health and Safety investigation into employer obligations for driver health monitoring