Coroner's Finding: Searle, Fiona
Deceased
Fiona Searle
Demographics
51y, female
Date of death
2021-05-08
Finding date
2024-10-31
Cause of death
traumatic closed head injuries sustained after falling from a ramp into a sunken sitting area while seated in an electric wheelchair
AI-generated summary
Fiona Searle, 51, died from traumatic closed head injuries sustained when her electric wheelchair fell from a ramp into a sunken sitting area at Glenorchy Primary School on 1 May 2021. Ms Searle was an experienced wheelchair user with spina bifida and multiple comorbidities. Investigation excluded seizure, medication effects, wheelchair malfunction, or suicide as causes. The accident resulted from Ms Searle miscalculating her position on the ramp and coming too close to the unguarded edge. The sunken sitting area lacked protective barriers—only green paint marking the edge, which blended with the floor. WorkSafe found the unguarded edge created foreseeable fall risk. Post-accident, bollards were installed on one side but not the other three sides of the sunken area. The coroner recommends complete fencing around all three unprotected sides with gated access to prevent future incidents involving wheelchair users and children.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- unguarded edge of sunken sitting area
- inadequate visual marking of edge with green paint that blended with floor surface
- miscalculation of position on ramp by wheelchair user
- absence of protective barriers or rails
- failure of design to account for foreseeable risks to wheelchair users and children
Coroner's recommendations
- A fence similar to existing fencing at the school should be erected around the three unprotected sides of the sunken sitting area
- A gate should be installed in the fence to provide access to the steps on each side of the sunken area
- Complete protective barriers are needed around all three sides of the sunken sitting area, not only the side adjacent to the ramp where bollards were installed
- Improved edge marking beyond green paint—such as yellow paint or rippled strips—should be used to indicate changes in concrete levels
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