Inquest into the death of William Brown

62y · Male·respiratory failure secondary to high cervical cord injury (C3/4 and C7/T1 fractures with ligamentous disruption and cervical spinal cord oedema and haemorrhage)

William Bernard Brown, a healthy 62-year-old, died from respiratory failure secondary to cervical spinal cord injury after being struck by a falling branch from an African Mahogany tree at a golf course. Six days after the impact resulted in quadriplegia and respiratory compromise, he chose to cease treatment. The coroner found the tree was dangerous due to inadequate maintenance and management. No regular inspection or arborist-led assessment had occurred despite previous similar deaths from African Mahogany trees and known risks. The contractor who performed limited deadwood removal in March 2014 identified the tree as dangerous requiring further work but failed to communicate this to the property leaseholder. Inadequate lease terms between the City of Darwin and the golf course operator created ambiguity about tree maintenance responsibility, and neither party resolved this despite being aware of the risks. The coroner concluded the death was preventable with proper tree management and maintenance protocols.