Coronial
WAcommunity

Inquest into the Death of Warren Bradley Jack

Deceased

Warren Bradley Jack

Demographics

29y, male

Date of death

2000-04-28

Finding date

2004-03-11

Cause of death

Head Injury

AI-generated summary

Warren Bradley Jack, 29-year-old fisherman, died from severe head injury after falling from a fishing vessel during a refuelling operation. On 24 April 2000, after returning from a fishing trip, he consumed approximately 2.5 large bottles of beer and a rum and cola drink between 1:30-3:00 AM while ashore. At 9:00 AM, while the vessel was being berthed at the fuelling dock, he stepped over a 790mm guardrail on the foredecks in good spirits and anticipation of upcoming leave. His foot caught on the rail, he fell head-first approximately 1.5 metres onto a concrete beam, suffering a large right subdural haematoma with subarachneal haemorrhage and extensive brain injury. He was airlifted to Sir Charles Gairdner Hospital in Perth where he underwent emergency neurosurgery but deteriorated with raised intracranial pressure and brain death. The coroner found the death was accidental, arising from a momentary miscalculation while intoxicated (blood alcohol 0.102%), compounded by impaired judgement. The coroner noted the guardrails and safety procedures complied with regulations and that such accidents could occur despite rigorous safety enforcement.

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

Contributing factors

  • Alcohol intoxication (blood alcohol level 0.102%)
  • Benzodiazepines in system (Temazepam trace)
  • Impaired judgment and coordination
  • Momentary inattention to safety
  • Unnecessary action stepping over guardrail
  • Fall from vessel onto concrete beam
  • Severe closed head injury with subdural haematoma and subarachneal haemorrhage

Coroner's recommendations

  1. WorkSafe to review its policy of representation at interviews and the extent to which employer representatives should be present, as this may discourage employees from raising safety concerns
  2. Development of ongoing employee education regarding hazard risk analysis and alcohol and drug abuse in the workplace
  3. Improvement of working relationship between the fishing industry and WorkSafe to assist with appropriate development of policy
  4. Guidance on alcohol in the workplace should provide small employers with concrete, practical guidance rather than general advice
Full text

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