Coronial
VICcommunity

Finding into death of Terry John Chandler

Deceased

Terry John Chandler

Demographics

42y, male

Date of death

2021-01-20

Finding date

2022-07-12

Cause of death

Drowning

AI-generated summary

Terry John Chandler, a 42-year-old inexperienced boater, drowned while fishing from a small recreational vessel in challenging sea conditions. He had consumed alcohol and cannabis before launching at night without a marine licence. His personal flotation device was only partially inflated. Key clinical lessons: substance use significantly impairs judgment and motor coordination in high-risk activities; the chest pain he experienced during the incident (possibly cardiac channelopathy) contributed to his inability to manage the situation effectively. Prevention hinges on education about basic boating safety, proper PFD maintenance and use, understanding weather/sea conditions, and never operating vessels while intoxicated. The case demonstrates how multiple risk factors—inexperience, substance impairment, inadequate equipment maintenance, and lack of formal training—combine to create fatal outcomes.

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

Error types

system

Drugs involved

alcoholcannabis

Clinical conditions

drowningpossible cardiac channelopathymild coronary artery atherosclerosis

Contributing factors

  • Inexperience in recreational boating and vessel operation
  • Lack of marine licence or formal boating certification
  • Alcohol consumption (approximately 0.06 g/100mL blood ethanol level)
  • Cannabis use (delta-9-tetrahydrocannabinol detected)
  • Impaired judgment and motor coordination from substance use
  • Challenging sea conditions with residual swell despite apparent calming
  • Personal flotation device partially uninflated on left side
  • Night-time operation of vessel without navigation lights
  • Possible acute cardiac event (chest pain episode during incident, possible cardiac channelopathy)
  • Decision to operate vessel despite partner's safety concerns
  • Attempt to salvage vessel rather than prioritize survival

Coroner's recommendations

  1. The Maritime Safety Division of Transport Safety Victoria should highlight and disseminate the circumstances of Mr Chandler's drowning in upcoming educational materials and safety promotional campaigns
  2. The Maritime Safety Division of Transport Safety Victoria should produce and disseminate awareness campaigns such as the 'Life Jacket Label-Read It' campaign to educate boaters on proper maintenance and functionality of personal flotation devices
Full text
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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.

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