Coronial
VICother

Finding into death of Andrew Hepple Pattison

Deceased

Andrew Hepple Pattison

Demographics

39y, male

Coroner

Coroner Audrey Jamieson

Date of death

2009-08-02

Finding date

2016-02-24

Cause of death

Positional asphyxia in a setting of intoxication and minor head injury

AI-generated summary

Mr Andrew Hepple Pattison, a 39-year-old regular patron of the Footscray Club, died from positional asphyxia after falling down stairs while heavily intoxicated. He had consumed approximately 10-12 pots of beer and was appropriately cut off by staff, who arranged a taxi. Approximately 30 seconds after leaving the club, he fell and was found with his head wedged against the wall in a position that compromised his airway. Over six minutes elapsed before emergency services determined he needed repositioning due to airway obstruction. Paramedics confirmed his airway was critically occluded. The coroner found his death was likely preventable had his airway been cleared and maintained promptly. Key issues included: lack of first aid training among club staff, delayed recognition of airway compromise, and difficulty repositioning him due to confined space. The staircase design complied with relevant building codes, though some ergonomic improvements were identified as practical enhancements.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicineforensic medicineparamedicine

Error types

communicationdelay

Drugs involved

alcohol

Clinical conditions

positional asphyxiaalcohol intoxicationhead injuryairway obstruction

Contributing factors

  • High blood alcohol concentration (0.31g/100mL)
  • Minor head laceration with reduced consciousness
  • Awkward body position with head wedged against wall
  • Airway obstruction from positioning
  • Delay in recognising airway compromise
  • Inability of untrained responders to effectively manage airway
  • Confined space hindering repositioning efforts
  • Lack of first aid training among staff

Coroner's recommendations

  1. Victorian Commission for Gambling and Liquor Regulation should consider incorporating first aid training material into resources made available as best practice to licensees
  2. Footscray Club should implement practical suggestions from ergonomic assessment including colour-contrasted nosing on stair treads, removal of landing hump, dual handrails, and improved lighting
  3. All licensed premises staff should undertake current first aid training despite lack of statutory mandate
  4. Clubs should consider their obligations under Occupational Health and Safety Act 2004 in relation to patrons
Full text

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