Finding into death of Trevor Henry McKie
Deceased
Trevor Henry McKie
Demographics
48y, male
Date of death
2020-08-11
Finding date
2023-05-02
Cause of death
Coronary artery atherosclerosis in the setting of immersion
AI-generated summary
Trevor McKie, 48, an experienced mariner, died from coronary artery atherosclerosis while attempting to transfer between boats during deteriorating weather on Lake Wellington. He fell overboard in rough conditions (seas to 2 metres, winds 50 knots) while wearing a self-inflating lifejacket that was not deployed, likely due to its poor condition—the trigger mechanism was corroded and extremely difficult to pull, the oral inflation mouthpiece was broken, and sand/corrosion were present inside. His decision-making may have been affected by mirtazapine, cannabis, and possibly alcohol detected post-mortem. Critical clinical lessons: (1) pre-existing severe coronary atherosclerosis predisposed to sudden cardiac arrhythmia during physical exertion and stress; (2) proper maintenance and regular servicing of safety equipment is essential; (3) weather forecasts must inform boating decisions; (4) emergency communication protocols need clarity on location-sharing; (5) polysubstance use in high-risk activities warrants assessment.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Severe coronary artery atherosclerosis predisposing to cardiac arrhythmia
- Deteriorating weather conditions not adequately considered before undertaking tow
- Non-functional self-inflating lifejacket with broken mouthpiece and corroded trigger mechanism
- Lifejacket not deployed when immersed in water
- Mirtazapine and cannabis use affecting decision-making and physical capacity
- Possible alcohol ingestion
- Heavy water-sodden clothing impairing buoyancy and movement
- Duckboard in raised position preventing easy re-boarding
- Inadequate emergency communication regarding location
Coroner's recommendations
- ST Vic consider reviewing current safety material to include information about annual service and testing of inflatable lifejackets with step-by-step guidance for owner checks or information about third-party service contractors
- ST Vic consider providing information about the importance of checking and remaining up to date with weather forecasts before leaving shore and whilst on water, including where to find up-to-date weather information and availability of weather applications such as Boating Vic
- ST Vic consider providing information directed to mariners to contact triple zero in emergency and what information should be communicated to triple zero call taker including location information expressed by latitude and longitude or reference to nearby landmarks
- ST Vic consider providing this information with annual renewal of vessel registration and consider feasibility of developing online test to be completed prior to renewal of registration
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