Coroner's Finding: East, Robert William
Deceased
Robert William East
Demographics
78y, male
Date of death
2022-03-18
Finding date
2023-10-04
Cause of death
subdural haematoma
AI-generated summary
Robert William East, 78, died from a subdural haematoma sustained when his electric wheelchair became uncontrollable on a gravel path in Glenmore Creek Reserve. He had consumed approximately five beers at the Granada Tavern and decided to ride his wheelchair home after waiting 45 minutes for a wheelchair-accessible taxi with an estimated 1-1.5 hour wait time. The wheelchair lost traction on the gravel path at a downhill bend, veering off into an embankment where it tipped and landed on him. Contributing factors likely included recent path re-gravelling, path camber, lack of lighting, mild intoxication, and excessive speed. The coroner identified that inadequate availability of wheelchair-accessible taxis forced a vulnerable, intoxicated patient to attempt an unsafe alternative journey. Systemic barriers to taxi service provision (poor remuneration for drivers) created a circumstance where a preventable death occurred.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- inadequate availability of wheelchair-accessible taxis
- lengthy taxi waiting times (1-1.5 hours)
- alcohol consumption (approximately five schooners of beer)
- loss of control of wheelchair on gravel path
- recent re-gravelling of path surface
- path camber
- lack of lighting on path
- excessive wheelchair speed
- unsafe decision-making while mildly intoxicated
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