Finding into death of John Edwin Wilks

Contributing factors

• Fall from wheelchair during bus turn
• Fractured ribs with small haemothorax
• Development of pneumonia and respiratory failure
• Paralysis of left side limiting ability to use grabrail for stability
• Lack of effective wheelchair restraint system on bus
• Bus turning manoeuvre at 26-27 kph

Coroner's recommendations

1. Public Transport Victoria, Bus Association Victoria and the Office for Disability form a working group to consider and recommend how the Bus Safety Act 2009 can be amended to require the mandatory installation of appropriate wheelchair restraints on Victorian public buses
2. The Minister for Public Transport engage with route bus operators to encourage adopting Ventura Bus Lines' policy of mandating the 'ironing board device' and tether belt in specifications for all new public buses
3. The Minister for Public Transport engage with route bus operators to review procedures for reporting injuries which occur on public buses
4. Public Transport Victoria, Transport Safety Victoria and the Minister for Public Transport request the Victorian Equal Opportunity and Human Rights Commission to conduct a review under section 41(c) of the Charter within 18 months of the decision
5. Each Public Authority should develop a plan to apply the Review's findings and recommendations to all bus transport systems within their remit within three months of the Review completion