The findings into the Coronial Inquest into the death of Kariong man, Mr Michael Johnson, were released on November 2. Mr Johnson died in 2014 after becoming trapped under his four wheel drive at a home he was doing construction work on in the Hunter Valley.
Following his death, Mr Johnson’s family expressed several concerns over the series of events that lead to Mr Johnson’s accident and the following response of emergency services. Deputy State Coroner and Magistrate, Ms Teresa O’Sullivan, presided over the Inquest, with her overall aim being to specify the series of events that led up to Mr Johnson’s death, and to review the subsequent response of emergency services, following representations made by the deceased’s mother, Ms Sue Johnson.
Eyewitnesses to Mr Johnson’s accident recalled that Mr Johnson had been drinking with other colleagues at the worksite during an afterhours barbecue, when he entered his vehicle and attempted to tow another colleague’s bogged vehicle. Mr Johnson, who was not wearing a seatbelt, then rolled his vehicle, becoming trapped underneath. In the fi ndings introduction, Ms O’Sullivan stated: “Although there does not appear to be any signifi cant confl ict between eyewitnesses as to what was done or not done, there was some confl ict as between those accounts and the family’s recollection of what they were told by eyewitnesses to the events of that evening, the next day, and some days following.
“In fairness to those involved and to Michael’s family, evidence was heard regarding these accounts.” The fi ndings detailed primary witness accounts in a breakdown of key events including: the accident, the triple zero call, the arrival and response of key emergency services such as the NSW Police and NSW Ambulance, and possible other attempts to free Mr Johnson. Following the accident, witnesses called triple zero. According to the NSW Ambulance Incident Detail Report, the call was made at exactly 12:17am. The witness who made the call also told the Inquest that he was advised by the operator not to attempt to move the vehicle. Witnesses also told investigators that they did make one attempt to move the vehicle with their own hands before NSW Police arrived on scene.
Prior to their arrival, witnesses remained in contact with the triple zero operator and relayed information about Mr Johnson’s condition regarding his pulse and breathing for what witnesses estimated to be 20 to 30 minutes before police arrived. Witness descriptions of Mr Johnson detailed a rapid decline in his physical condition, including erratic breathing, weakening pulse and the purpling of his skin. Senior Constable Lana Mallam and Senior Constable Jonathon Cassidy arrived at about 12:38am. Sen Con Mallam went to Mr Johnson and could observe no signs of life, but a witness, who was nursing Mr Johnson’s head in his lap, said he could detect breathing.
“Sen Con Mallam noticed that the tool box lid on the rear tray appeared to be keeping the vehicle propped slightly off the ground. Sen Con Mallam thought she told radio there may be a faint pulse; the VKG record said: ‘patient not in a good way, I think I have a faint pulse,’ at 12.41am, (Inquest Findings 2016).” Sen Con Mallam told the Inquest that she instructed witnesses at the scene not to attempt to move the vehicle until an ambulance offi cer was present. Ambulance records show paramedic, Mr David Foote, arriving on scene at 12:49am and the Inquest heard how ambulance crews who did attend had to be contacted at their residences, as there was not an on-site presence at that time of night at the Singleton base. Offi cer Foote met up with two other paramedics at the ambulance station, and then drove separately to the scene while the others came in a rescue truck. When Mr Foote arrived, he found Mr Johnson unconscious with no pulse or respirations.
He asked the bystanders to help lift the vehicle to release the compressive force so that Mr Johnson could be removed from under the vehicle. The ambulance protocol that he applied was to extract the patient as rapidly as possible in circumstances where they had not been trapped for an extensive period of time. CPR was carried out, but Mr Johnson was unable to be revived. The Inquest was also told of one other attempt to free Mr Johnson. One witness told the Inquest that he had fetched a carjack after police arrived, but the jack was never utilised in the attempt to remove the vehicle from Mr Johnson. Ms Johnson also told investigators that a witness informed her a tractor had been called for to assist in the removal.
The Inquest determined that the tractor was never actually called for, and that given the high pressure situation, the witness may have thought the call had been made when he relayed this information to Ms Johnson. Mr Johnson’s family raised several concerns over the events and actions of witnesses and emergency services that culminated in Mr Johnson’s death. Major concerns raised by Mr Johnson’s family included the time difference between the triple zero call and the arrival of NSW Ambulance Offi cers (32 minutes), the fact that a call was made to NSW Fire Brigade but was the RFS called off and stood down, the lack of a CT scan following Mr Johnson’s death which could have revealed the presence of further injuries, and the duty of care ignored by Mr Johnson’s colleagues who failed to stop him from driving under the infl uence.
In a victim impact statement, Ms Johnson told the Inquest the death of her “golden child” had devastated the lives of her family and that her son had been systematically failed by his friends and emergency services. “I don’t understand why everything that could go wrong, did go wrong that night,” Ms Johnson said in her statement. “The pain I feel at his loss is indescribable. “My son had a right to live and I believe that right was taken away from him.” Mr Johnson’s cause of death was ruled as traumatic asphyxia and medical experts involved in Mr Johnson’s post-mortem told the Inquest a CT scan had not been performed due to this ruling. Ms O’Sullivan also expressed her confidence in the findings of the medical personnel involved and that the evidence provided to these professionals indicated head injury was not the cause of death. Ms O’Sullivan also noted that a visual examination and x-ray also revealed no signifi cant signs of head trauma. The Inquest concluded that Mr Johnson died of traumatic asphyxia due to the rolling of his vehicle and his being trapped beneath it. Ms O’Sullivan then closed the Inquest on November 1.
Inquest Findings, Nov, 2, 2016 Teresa O’Sullivan, State Deputy Coroner Journalist, Dilon Luke