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Crown Solicitor's Office

Recent inquests

Inquest into the death of Manjit Singh

On 17 August 2015 Deputy State Coroner Dillon delivered findings in relation to the death of Indian national, Manjit Singh, who came to Australia on a 457 visa. Mr Singh was sponsored to be a chef in an Indian Restaurant in Darlinghurst and his sponsor promised him a salary of $800 per week. Instead, in statements to the Australian Federal Police, Mr Singh said his sponsor required that he work 16 hour days and sleep in a locked storeroom at the restaurant. He also had limited access to food and did not receive the promised salary.

Prior to entering Australia, Mr Singh was identified as having latent tuberculosis (TB). Mr Singh's TB was activated while he was in Australia. Although he had periods of in-patient and outpatient medical treatment, Mr Singh experienced difficulties with employers and visas, and the consequent lack of funds and malnutrition impacted upon his health. On 29 August 2011, aged 33 years, Mr Singh died following lung surgery for the treatment of severe pulmonary TB, with malnutrition contributing to the development of that disease. 

Deputy State Coroner Dillon made recommendations to the NSW Minister of Health for the review of recent radiologist's reports on x-rays and face to face interviews prior to discharging patients screened for TB. He also recommended that the Minister for Immigration and the NSW Minister for Health confer to find optimal policies for the protection of both temporary visa holders on TB health undertakings and the public health.

For more information, please call Johanna Geddes on (02) 9224 5251.

Inquest into deaths related to rockfishing

On 2 July 2015, Deputy State Coroner Forbes delivered findings in the joint inquest into the deaths of nine people who had drowned while engaged in rock fishing on the NSW coastline between July 2012 and February 2015.

The inquest was conducted over a week in June 2015. It followed two separate inquests in 2011, both of which also considered multiple rock fishing deaths. While various recommendations were made and measures were put into place, a further 35 people had died during rock fishing activities since 2012. Apart from determining the manner and cause of each of the nine deaths, the primary purpose of this inquest was to consider what more might be done to make rock fishing safer and to prevent further rock fishing deaths in the future.

Most of the deaths occurred after the victim was swept into the water while engaged in rock fishing or while attempting to save a friend in such circumstances. Evidence was heard that of the nine deceased, only one was wearing a life-jacket at the time of death. None of the nine deaths had occurred on days on which warnings were issued for dangerous weather conditions, and many of the deceased were experienced rock fishermen. Evidence was led that rock fishing locations tend to be isolated and away from immediate assistance, and that tidal, wave and weather conditions at apparently safe locations can become dangerous. In such circumstances, those swept into the sea would have been best assisted by a life-jacket to keep them afloat long enough for assistance to arrive.

Deputy State Coroner Forbes made recommendations for the introduction of legislation requiring the mandatory use of life-jackets by those engaged in rock fishing. Other recommendations related to furthering that requirement, such as subsidies and dedicated education campaigns promoting the use of life-jackets and the installation of further signage at known rock fishing sites.

For more information, please call Catherine Follent on (02) 9224 5169.

Inquest into deaths related to the use of quad bikes

The Crown Solicitor assisted Deputy State Coroner Freund in the joint inquest into the deaths of nine people in NSW, whose deaths arose from the use of quad bikes or similar vehicles between February 2009 and August 2014. During the inquest, four other deaths were also considered. The inquest was conducted over three weeks in February, July and August 2015. Her Honour delivered findings on 2 November 2015.

Over recent years, quad bikes have become the biggest killer of workers on farms in Australia. There have been over 200 quad bike related deaths in Australia since 2011. The inquest before Deputy State Coroner Freund followed a similar joint hearing in Queensland, where the presiding Coroner had made significant recommendations likely to impact upon the use of quad bikes, particularly in the agricultural sector.

In considering what might be done to make the use of quad bikes and related vehicles safer and to prevent future fatalities and injuries from occurring, the inquest examined the circumstances of each death, how the design of the vehicles affects rider safety, how the behaviour of the rider affects the stability of the vehicle, and how the vehicles are marketed to consumers. Evidence was given by various witnesses, including experts in farming, medicine, engineering and vehicle safety development.

In most of the cases before Deputy State Coroner Freund, death resulted from circumstances in which the vehicle had rolled over, trapping the rider underneath and causing severe injuries to the rider. Her Honour made recommendations that a safety rating system for quad bikes be introduced, which would provide independent information to assist prospective purchasers. Her Honour also made recommendations in relation to implementing standards in relation to the design, manufacture, importation and supply of quad bikes, developing training packages for the operation of quad bikes, and considering the use of helmets, crush protection devices and seatbelts. Other recommendations included prohibiting children under the age of 16 from using adult-sized quad bikes and conducting a public media campaign to increase awareness in persons engaged in rural activities in NSW.

For more information, please call Catherine Follent on (02) 9224 5169.