Coroner's Finding: Tolputt, Trevor
Deceased
Trevor John Tolputt
Demographics
55y, male
Date of death
2016-07-14
Finding date
2019-05-21
Cause of death
hypothermia
AI-generated summary
Trevor Tolputt, a 55-year-old man, died of hypothermia on 14 July 2016 while walking the Overland Track alone in severe winter conditions. Despite being reported by another walker at 6-7 pm as not reaching Narcissus Hut, this critical information was not relayed to Parks and Wildlife Services or police until the following morning, delaying rescue by ~12 hours. However, expert evidence established Tolputt would have died by approximately 6:30 pm, making even a timely rescue unlikely given severe weather preventing helicopter response. Key clinical lessons: Tolputt wore inadequate winter gear (non-seam-sealed jacket, no beanie, lean physique), was severely hypothermic when last seen at 4:15 pm appearing only tired, and refused assistance from experienced walkers. The inquest identified systemic failures in communication between the private ferry operator and PWS, lack of emergency procedures, poor inter-agency relations, and gaps in the Walker Safety Checklist. Preventive measures should include stronger messaging on winter preparation, enhanced equipment requirements, mandatory visitor centre presentation, and improved communication protocols between PWS and commercial operators.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- inadequate winter clothing
- low body weight and minimal body fat
- walking alone in extreme weather
- failure to accept assistance from other walkers
- lack of planning for delays
- delayed reporting to emergency services
- poor communication between Parks and Wildlife Services and ferry operator
- power outage affecting communications
- decision to continue walking despite severe conditions
Coroner's recommendations
- PWS to review Walker Safety Checklist to ensure clothing is adequate for winter conditions, in particular requiring waterproof jacket and over-pants that are seam-sealed and made of breathable fabric such as Gore-Tex
- PWS to produce a video on development and prevention of hypothermia whilst walking and disseminate pertinent information regarding safety considerations of walking in winter on the Overland Track
- PWS to develop and implement a strategy to strongly encourage all walkers to present at either Cradle Mountain or Lake St Clair visitor centres prior to commencing the Overland Track in the non-booking season
- PWS to update its Lost or Missing Walker Policy to reflect that it applies to reported 'overdue' as well as lost or missing walkers, develop guidelines ensuring PWS staff notify Tasmania Police at an early stage of such reports, and provide ongoing staff training
- PWS to investigate and implement after-hours availability of PWS staff at Lake St Clair and Cradle Mountain visitor centres
- PWS and LSCL to jointly conduct staff induction procedures concerning the role and requirements of each organisation in respect of overdue or missing walkers, provide documentation to staff, repeat induction annually, and consider separating safety induction from other staff induction
- Senior Ranger (PWS) to devise and implement a strategy to ensure full compliance with the protocol in the lease requiring effective communication between PWS operational staff and LSCL staff
- EGI to nominate a suitable LSCL staff member responsible for ensuring ongoing and effective communication and cooperation with PWS in the visitor centre complex, particularly regarding walker safety
Further listening
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