Inquest into the 4 Deaths at Mount Augustus

Contributing factors

• extreme heat and reflected heat from rocks
• inadequate fluid intake
• lack of acclimatisation to hot conditions
• insufficient pre-visit warnings
• no mobile phone communications on summit trail
• no emergency response resources at or near site
• long distance to carpark and emergency services
• visitors walking during hottest part of day
• underestimation of walk difficulty and duration
• inadequate water supply recommendations
• insufficient signage regarding specific dangers
• lack of shelter or rest areas
• limited trail markings
• age-related physiological vulnerability
• pre-existing medical conditions affecting heat tolerance

Coroner's recommendations

1. Close the Summit Trail and Gully Trail at Mt Augustus National Park from 1 November to the end of February each year under relevant regulations
2. Close the Summit Trail and Gully Trail from 1 September to 31 October and 1 March to 30 April after 7.00 am each day, so all visitors must commence walks before 7.00 am unless undertaking guided ranger walks
3. Explore options for Tourist Park to facilitate a short-term PLB loan scheme similar to Purnululu National Park with DBCA-supplied stock
4. Improve signage with explicit warnings about heat dangers, age-related risks, previous deaths, minimum water requirements (6 litres per person), and minimum time estimates (6-8 hours)
5. Update all Mount Augustus websites with explicit danger warnings including number of deaths, extreme temperature risks, and who should not attempt the walk
6. Install clearer, more visible trail markings at higher points so walkers can see them from distance
7. Install additional distance markers (every 500m-1km) and shelter/rest stations along the summit trail, particularly at halfway point
8. Provide emergency information forms and trip intention forms for visitors to complete and leave on vehicle dashboards
9. Ensure DBCA emergency management equipment (defibrillator, medical kits, stretchers) is positioned at Tourist Park for quick access
10. Facilitate training for Tourist Park staff in first aid
11. Develop formal Memorandum of Understanding between police and Burringurrah Community Nursing Post regarding emergency response protocols and authority for nurses to leave post
12. Ensure at least one remote area nurse with IV capability is rostered at Burringurrah Community Nursing Post at all times
13. Prioritise upgrading Mount Augustus airstrip to allow RFDS night landings following consultation with Wajarri community
14. Improve mobile phone coverage at Mount Augustus through installation of three small-celled towers on western and eastern sides of the rock
15. Investigate establishment of mid-west based rescue helicopter with winching capability (already under government consideration)
16. Establish permanent memorial at base of Summit Trail to commemorate those who have died, in consultation with deceased's families and Wajarri traditional owners
17. Engage Curtin University Consumer Research Lab and develop comprehensive public safety communications plan around hydration, heat risks, and prior deaths
18. Increase DBCA ranger presence at Mount Augustus throughout the year, including low season
19. Reinstate DBCA volunteer camp ground host program at Tourist Park
20. Support development of ranger-guided walk program in consultation with Wajarri Yamatji Corporation and traditional owners
21. Ensure Traditional Owner rangers are informed immediately of missing person incidents and can assist with searches
22. Provide proper remuneration and equipment for Indigenous rangers assisting with emergency response