Coroner's Finding: ORGAN Kelly

18y · Female·hypoxic encephalopathy due to raised intracranial pressure caused by severe closed head injury

An 18-year-old woman died from hypoxic encephalopathy due to severe closed head injury sustained when she fell from a shade sail structure at a playground. While climbing on the sail with friends after consuming minimal alcohol, a support post failed due to inadequate welding at the base. She fell approximately 2.5 metres onto a pine log border, sustaining a fractured skull and multiple intracranial haemorrhages. The coroner identified multiple preventable failures: inadequate metal fabrication with substandard welding only 50% of design specification; failure to install reinforcing gussets to all posts after a previous failure in 1998; design that failed to account for foreseeable misuse despite prior knowledge of climbing; and placement of a hard border directly below the fall zone. The structure was not designed for the loads applied but access was easy due to insufficient clearance. Engineering review after the death revealed systemic construction defects across similar structures.