Coronial
TAScommunity

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. Report an inaccuracy.

Specialties

emergency medicineneurosurgeryintensive care

Error types

system

Clinical conditions

subdural haematomatype 1 diabetesperipheral vascular diseasehistory of myocardial infarction

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
Full text

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.