Finding into death of Max Edward Loweke
Deceased
Max Edward Loweke
Demographics
63y, male
Date of death
2016-01-04
Finding date
2021-12-08
Cause of death
Drowning
AI-generated summary
Max Edward Loweke, aged 63, drowned after his car was washed off Delatite Road at Whiteheads Creek Ford during flooding on 4 January 2016. The coroner found that while drowning was the medical cause, the death was likely preventable through better emergency management coordination. Key failures included: emergency services (police and SES) failing to deploy warning signs or close the road despite knowing the ford was impassable; the Council's after-hours duty officer falling asleep before deploying requested resources; Oracle's telephone system incorrectly requiring a 10-digit callback number, delaying contact; and lack of formal implementation of the Emergency Management Manual structure. Police and SES staff knew by 1:05am that requested Council resources had not been provided but did not reiterate requests or establish interim warnings. The coroner noted that closing the road or deploying signs shortly after 10:30pm or midnight, or placing interim warnings, would likely have prevented the death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Failure to deploy warning signs at flooded ford despite multiple requests
- Failure to close Delatite Road when known to be impassable
- Lack of interim warning measures placed at ford between 11pm and 1:55am
- Council after-hours duty officer falling asleep before providing requested resources
- Oracle telephone system requiring 10-digit callback number, delaying initial contact with duty officer
- Police and SES staff not reiterating requests to Council at 1:05am when they learned resources had not been provided
- Lack of formal implementation of Emergency Management Manual structure for coordination
- Inadequate briefing and training of Council after-hours duty officer
- Deceased had mobility limitations due to prior spinal surgery and bilateral knee prostheses
Coroner's recommendations
- Victoria Police and Victoria State Emergency Services consider augmenting emergency management training to ensure all organisations and personnel involved in an emergency are explicitly informed that the Emergency Management Act and Manual are being applied, including identification of the Control Agency and the names of those appointed to defined roles such as Incident Controller, Police Commander, Municipal Emergency Response Coordinator, and Municipal Emergency Response Officer
- At meetings conducted within and across organisations involving emergency management roles, the meetings be explicitly declared as Emergency Management Team Meetings, be minnuted, and minutes list the names of people appointed to defined roles
- Emergency services personnel who may adopt the role of Incident Controllers (and in the case of Victoria Police those who may fulfil the role of Police Commander and Police Forward Commander) undergo formal risk assessment training
- Victoria Police and Victoria SES and other relevant parties engage in regular practical exercises such as mock emergencies conducted in a realistic fashion, including in regional areas, rehearsing the implementation and use of the Emergency Management Manual structure in various emergency circumstances
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