Coronial
VICcommunity

Finding into death of Bikram Dangol

Deceased

Bikram Dangol

Demographics

30y, male

Coroner

Coroner Kate Despot

Date of death

2018-07-26

Finding date

2026-04-09

Cause of death

Head and neck injury in a motorcycle incident

AI-generated summary

A 30-year-old male motorcyclist died from head and neck injuries sustained in a motorcycle incident on the Western Ring Road on-ramp on 26 July 2018. The coroner found that a water leak from a fire hydrant on VicRoads-owned infrastructure created a wet patch on the road surface. This wet patch, combined with poorly prepared road markings (black-painted lines without adequate abrasive material) that eliminated macro and micro texture, resulted in loss of traction when the motorcycle crossed the painted line. The coroner identified significant system failures: a water leak was reported to Greater Western Water in May 2018 but remained unrepaired for approximately 2.5 months due to delays in identifying the correct VicRoads contact person, poor inter-agency communication, and lack of documented asset ownership protocols. While not entirely preventable, the death may have been mitigated if the water leak had been addressed promptly and road markings properly prepared.

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

Specialties

forensic medicine

Error types

systemcommunicationdelay

Contributing factors

  • Water leak from fire hydrant on road surface
  • Poor road surface conditions at collision location
  • Road markings prepared inadequately - black paint without abrasive material reducing surface friction
  • Delay in identifying asset ownership (fire hydrant owned by VicRoads)
  • Lack of documented contact procedures between Greater Western Water and VicRoads
  • Inter-agency communication failures
  • Water leak reported in May 2018 but not repaired until 26 July 2018
  • Section of road surface without macro and micro texture due to black paint application

Coroner's recommendations

  1. That the Department of Transport and Planning consider working with all water authorities in Victoria to establish a shared asset register to expedite communication in relation to asset management and maintenance
Full text

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