Coronial
VICcommunity

Finding into death of Alfred Norman Avage

Deceased

Alfred Norman Avage

Demographics

79y, male

Coroner

Deputy State Coroner Paresa Spanos

Date of death

2014-09-04

Cause of death

head injuries sustained in a fall from a bicycle

AI-generated summary

A 79-year-old man died from head injuries sustained in a bicycle fall on a rural road. While riding at approximately 40 km/h on a descent, he swerved to avoid mud and debris on the road surface, struck another cyclist's rear wheel, and fell heavily onto bitumen. He sustained a large acute subdural haemorrhage deemed non-survivable. The coroner identified that paramedics did not notify police despite recognising life-threatening injuries, though this delay did not affect outcome. Key learning: paramedics should consider notifying police of serious falls to enable scene investigation and road hazard identification. Road maintenance protocols and debris management from property access points warrant review to prevent similar incidents.

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

Specialties

neurosurgeryemergency medicineparamedicineforensic medicine

Error types

communicationsystem

Clinical conditions

acute subdural haemorrhagetraumatic brain injuryhead injury

Contributing factors

  • mud and debris on road surface at crossover point
  • steep descent on minor bitumen road
  • attempted manoeuvre to avoid hazard at speed
  • contact with another cyclist
  • large acute subdural haemorrhage with midline shift
  • delayed police notification despite life-threatening injuries recognised by paramedics

Coroner's recommendations

  1. Ambulance Victoria to approach Victoria Police and Emergency Services Telecommunications Authority to review circumstances of when police should be notified about serious falls
  2. Review of road maintenance and debris management protocols at property access crossovers to prevent hazardous materials on road surfaces
  3. Wellington Shire Council to continue implementation of Road Management Plan with appropriate response times and inspection frequencies for roads with debris hazards
Full text

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