Finding into death of Garry William Ledger

78y · Male·Complications of acute renal impairment in the setting of pelvic and lumbar fracture sustained in a fall in a man with idiopathic cardiomyopathy

Garry Ledger, 78-year-old South Australian visitor, died three weeks after falling on a Melbourne tram on 28 August 2025. While boarding tram route 16, he fell during tram acceleration while using his Myki card and before securing a handhold. He sustained severe injuries: comminuted L4 vertebral fracture (20% height loss) and right pubic rami fractures. The Alfred Hospital provided appropriate trauma care, but he developed acute renal impairment, delirium, and elevated inflammatory markers. His underlying conditions—idiopathic cardiomyopathy, atrial fibrillation, and chronic kidney disease—complicated his recovery. He died 20 September 2025 from asystolic cardiac arrest despite resuscitation efforts. The coroner found clinical care was appropriate with no errors identified. Concerned by six tram-fall deaths in Victoria since 2010 (all aged 60+) and 129 annual hospitalisations from tram falls, the coroner emphasised prevention. Recommendations include future tram upgrades with pre-boarding ticketing systems and stop buttons near priority seating, plus enhanced safety campaigns for older passengers.