Coroners act, 1975 as amended

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An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 6th and 7th days of April 2005, 27th and 28th days of February 2006, 15th day of March 2006 and the 10th day of May 2006, by the Coroner’s Court of the said State, constituted initially of Wayne Cromwell Chivell, State Coroner and subsequently of Mark Frederick Johns, State Coroner for the said State, into the death of Adam Edward John Sloan.

The said Court finds that Adam Edward John Sloan aged 15 years, late of 8 Alice Crescent, Burton, South Australia died at the Royal Adelaide Hospital, North Terrace, Adelaide, South Australia on the 23rd day of February 2002 as a result of right haemothorax due to lacerations of right lung. The said Court finds that the circumstances of his death were as follows:

  1. Introduction

    1. This Inquest was commenced by the court constituted of his Honour Wayne Cromwell Chivell who presided at the hearings of the Inquest in 2005. The remainder of the Inquest was heard by the court constituted of the present State Coroner.

    2. Accordingly, clause 25 of the schedule to the Coroner’s Act 2003 is relevant. Subclause 25 (2) provides as follows:

‘If an inquest held under the repealed Act had not been completed before the commencement of this Act, the proceedings will continue under this Act as if the coroner holding the inquest were the Coroner’s Court.’

The Coroner’s Act 2003 came into operation on 1 July 2005. Accordingly, the 2005 proceedings in this Inquest were held under the repealed Act but were not completed before the commencement of the Coroners’ Act 2003. The proceedings therefore continued under the Coroner’s Act 2003 as an inquest being held by the Coroner’s Court as established under section 10 of the Coroner’s Act 2003.

    1. Section 14 (3) of the Coroner’s Act 2003 provides as follows:

‘If the Coroner constituting the court for the purposes of any proceedings dies or is for any other reason unable to continue with the proceedings, the Court constituted of another Coroner may complete the proceedings.’

Mr Chivell was appointed a judge of the District Court of South Australia on 1 July 2005. He was therefore unable to continue with the proceedings in this Inquest, and accordingly Section 14 (3) of the Act was enlivened, and it is pursuant to that section that the present State Coroner completed the hearing of the Inquest.

    1. Adam Edward John Sloan who was born on 6 December 1986 died on 23 February 2002 at the Royal Adelaide Hospital. He was therefore 15 years old when he died.

    2. Adam died of the injuries that he sustained while he was a passenger in the front seat of a motor vehicle involved in an accident on the evening of 22 February 2002.

    3. A post mortem examination was conducted by Dr John Gilbert. Dr Gilbert attributed the cause of Adam’s death to “right haemothorax due to lacerations of the right lung”. Dr Gilbert described in his report that the lacerations were to the lower and middle lobes of the right lung resulting in haemorrage. The lacerations and haemorrage were due to blunt chest trauma which was associated with right posterior rib fractures.

  1. Circumstances of accident

    1. On 22 February 2002 Adam Sloan was one of a large number of young people who were present at the house of Jeffrey Ross Williams at 200 Whites Road, Paralowie. Most of the young people there appear to have been aged between 13 and 15 years. The only adult present was Mr Williams, who was then aged 42 years.

    2. The evidence showed that parties of young people, mainly young males who were friendly with the young sons of Mr Williams (also in their early teenage years) would attend at Mr Williams house. The evidence showed that Mr Williams’s backyard had been converted into a kind of BMX track at which the boys would ride bicycles. On Friday evenings it appeared to be customary for the young people to gather at the house and socialise. It appeared to be a regular feature of these gatherings that Mr Williams would obtain alcohol that would be provided for consumption by the young people present.

    3. A summary of a typical Friday night at Mr William’s house is contained in the statement of his son Robert Raymond Williams, then aged 15 years:

'On Friday the 15th of February, 2002 I went to dad’s house at about 6:00pm and was going to stay there for the weekend. There was a party happening at the house that Friday night but for no specific occasion. It was just a meeting place for a small group of friends. We usually drank alcohol at the party and would get friends that we know to buy the alcohol for us. Dad had done it for us some times. He just wanted us to have some fun. Dad was all right most of the time with us drinking alcohol there. That night there would have been about 30 to 35 people there with the ages of everyone ranging between 14 and 17 years. There was alcohol there but not everyone was drinking.'
(Exhibit C19a, p2)

    1. The events of the evening of 22 February 2002 culminated in the collision of a Mitsubishi Magna motor vehicle in which Adam Sloan was one of five occupants, with a large tree on the premises at 196 Whites Road Paralowie, a house just down the street from the scene of the party at 200 Whites Road Paralowie. It was this collision that resulted in Adam’s death.

    2. The driver of the vehicle was another young male, aged 15 years at that time, who was present at the party at Mr William’s house. This young man was charged with causing the death of Adam Sloan by dangerous driving and with causing grievous bodily harm to another young man who was a passenger in the car by dangerous driving, and with a further charge of causing grievous bodily harm to Mr Jeffrey Williams, the owner of the house, by dangerous driving. These charges were heard in the youth court of South Australia by Senior Judge Moss. The driver was found guilty on all counts on Friday 19 March 2004. Section 63C of the Young Offenders Act 1993 provides as follows:

‘A person must not publish by radio television newspaper or in any other way, a report of proceedings in which a child or youth is alleged to have committed an offence, if –
 (b) the report –

(i) identifies the child or youth or contains information tending to identify the child or youth; or

(ii) reveals the name, address or school, or includes any particulars, picture or film that may lead to the identification, of any child or youth who is concerned in those proceedings either as a party or a witness.’

It does not seem to me that Section 63C of the Young Offenders Act 1993 was intended to apply to a publication by another court in different proceedings of the name of a youth alleged to have committed an offence, even if the decision of the other court could in some way be described as a report of the proceedings in the Youth Court. However, it seems to me that it would be inappropriate for the Coroner’s Court to publish a finding which included information of the kind intended by section 63C to be maintained as confidential. Therefore, in these findings I will not refer to the driver of the vehicle or any of the other juvenile witnesses to the events of the evening of 22 February 2002 by name. Furthermore, I will refrain from including any information that might lead to the identification of the driver or any of the other witnesses.

    1. Mr Williams, the owner of the premises at 200 Whites Road, gave evidence before the Youth Court. He stated that he had no recollection of the accident or of the time within two months either side of the accident. He said that friends of his two sons, who were 13 and 16 years of age at the time of the accident, would often come to his house but to his knowledge none of them had ever driven his car. He did not drive his car as he himself had been disqualified from holding or obtaining a driver’s licence. He received terrible injuries in the accident. According to the reasons for decision of the Senior Judge, Mr Williams was in a coma for two months following the accident. His left arm was severed from his body, his face was badly injured and he had numerous operations during 2002. As at 2004 he still faced further operations upon his face and his back.

    2. One of the young males in the Magna told the Youth Court that there had been a party at Mr William’s house that night. This witness went with Adam Sloan, the boy who drove the car in the accident, and another young male. He said there were about 10 other young people present, aged between 14 and 16. A number of the young people present contributed money for the purpose of buying alcohol and Mr Williams agreed to make the purchase for them. Mr Williams said that he could not drive but other people present offered to do so. The witness said that Mr Williams went outside and detached a trailer from the Magna vehicle and then he and four of the boys entered the car. According to this witness, one boy started driving the car and then stopped, saying that he could not drive. Another boy then got into the driver’s seat, reversed out of the drive way and then drove to a nearby bottle shop where Mr Williams purchased the alcohol. This witness was present in the Magna vehicle during this trip and the subsequent accident. At the bottle shop, Adam Sloan got into the front passenger seat and Mr Williams got into the back. Mr Williams was carrying a carton of liquor.

    3. This witness could remember little of the journey or of the circumstances of the accident. He suffered a broken pelvis and a broken arm and lacerations to his head. He remembered that the vehicle had become “a bit air borne” before the collision with the tree.

    4. Another boy gave a similar story, although he said that on the way back from the bottle shop the driver pulled over to allow Adam Sloan to drive the vehicle. He said Adam drove normally for a short time and then stopped the car and the first boy got back into the driver’s seat and drove back towards Mr William’s house. He could not remember the accident either. He remembered someone saying, “the brakes aren’t working” before the accident.

    5. Another witness, Wendy Newchurch, was driving her vehicle along Whites Road that evening in the course of her work as a pizza delivery driver. She was approaching the junction with Camelot drive when she saw the lights of another vehicle driving down Camelot Drive. She then saw a “black thing go flying past” which then crashed into a tree on the Eastern side of White’s Road. She estimated the vehicle’s speed at between 80 and 100 kilometres per hour. She alighted from her vehicle and ran to the Magna to assist the occupants. Another vehicle came along shortly afterwards and one of the occupants of that vehicle said:

'What the fuck are they driving the car with no fucking brakes for?'
(Exhibit C27a, p3)

    1. Mrs Newchurch was accompanied by a 15-year-old girl who also witnessed the accident. This witness estimated the speed of the Magna at between 80 and 100 kilometres per hour.

    2. Another witness, Kym Driesener, whose statement was tendered as Exhibit C29a was driving behind the Magna on Camelot Drive. He said he saw the Magna approach the junction with Whites Road, move sharply to the right and then to the left as if the driver was trying to give himself room to take the corner then veer to the left mounting the curb on Camelot Drive and then shooting across Whites Road with two wheels off the ground. It then hit a gutter on the other side of the road and crashed into the tree. At no stage did he see the brake lights illuminated. Mr Driesener estimated the speed of the Magna at about 80 kilometres per hour.

    3. Another witness, one of the young people at the party, saw the crash from Mr William’s yard. She went over to the scene and overheard one of the bystanders asking the driver of the car why he did not use the brakes. She heard the driver reply:

‘Why didn’t you tell me the brakes didn’t work, then I wouldn’t have drove.'
(Exhibit C8a, p4)

    1. Another witness was a young boy who had been at the party. In a statement to police that was received as Exhibit C13a, this boy described what happened after the trailer was removed from the car by Mr Williams. He stated:

‘I saw Jeff get into the front passenger seat….There was no one sitting in the driver’s seat so I went and got in. At that time the motor was not running. I started the car up and prepared to reverse down the driveway. Jeff did not say anything to me at all. He would have thought that I was the one that was going to drive to the shop.

I put my foot onto the brake and had to push it right down to the floor for it to get hard. The car was an automatic and I put it into reverse. When I put it in reverse the car didn’t move initially until I released the brake and it started moving backward. Jeff did not ask me about my driver’s licence at all. I don’t think that I look old enough to have a driver’s licence either. Jeff knows me a little bit but he doesn’t know my age. He should have known by my looks that I wasn’t old enough to drive but he let me drive anyway.

I only reversed the car about a car length and then put my foot back on the brake pedal. Again the pedal went down to the floor and the car began to slow but wasn’t going to stop. I pushed the pedal down a couple of times before it did stop. I then put the car into Park and got out. Some people were laughing and I told them “The brakes didn’t work.” I didn’t say it to Jeff, just to the people that were there in the front yard. I wasn’t going to drive anyway.’

The witness went on to describe how the youth who was eventually convicted of the driving offences referred to above then assumed the position of driver and drove the car away. The witness stated that the next time he saw the car was some 40 minutes later as it was travelling along Camelot drive. He estimated its speed between 80 and 100 kilometres an hour. He stated that when the car was near the corner of Whites Road he knew that something was wrong. The car did not slow down at all. He identified the youth who was eventually charged with the driving offences as the driver of the vehicle. He saw the left side of the car mount the curb on the left side of Camelot Drive just before the intersection and stated that it looked as if the driver was attempting to turn left onto Whites Road. The witness thought that the accelerator must have been stuck. He stated that the car went straight across Whites Road, mounted the foot path on the side of the road on which he and the other witnesses were standing and drove straight into some trees. He stated that he saw the driver’s side of the car hit one of the trees and then the front passenger side of the car collided with another tree. When the car hit the trees, the rear of the car rose into the air a little bit.

    1. The same witness stated that he went to the car and saw the driver climb out of the car through the driver’s front window. The witness went around to the passenger side of the car and saw that Adam Sloan was sitting in the front passenger seat and another young person was sitting behind him in the back seat screaming. He said he saw Jeff sitting in the rear seat.

    2. He stated that he was aware of the party at the house the previous week, which has already been referred to. He stated that he remembered that there was beer at the house on that occasion and that lots of people had helped themselves to it. Later he stated that he had never driven a car before that night at all but that he did not believe that the brakes felt faulty for that reason alone. He stated that the only reason that the pedal stopped when he pushed it down was that it was hard up against the floor.

    3. A number of other people gave statements to police, which were tendered as exhibits at the Inquest. These statements contained very similar accounts of what happened. Many of the witnesses remarked upon the observations that the brakes did not appear to work on the vehicle.

    4. One such person was the adult witness Tina Ann Green whose statement appears as Exhibit C25a. She stated that she had known Jeff Williams for some two and a half years. She would assist Jeff with driving him to various appointments because he was not allowed to drive.

    5. She stated that Jeff would occasionally give her small sums of money for this assistance. When she first met Jeff he already owned the Mitsubishi Magna sedan that was eventually involved in the accident. She stated that most of the time when she would drive him somewhere she would use his car for that purpose and this occurred on average two or three times a week. She stated that Jeff was an alcoholic. She stated that over the last month prior to the crash she had noticed that the brakes were starting to wear out and needed replacing. She stated that the car would still stop when the brakes were applied and that the pedal would go about three quarters of the way to the floor. She stated that she thinks that she told Jeff about three times that the brakes needed fixing. She stated that in the week prior to the crash she would have driven the car at least twice. She stated that during that period the brakes were getting worse but she did not think that the car was dangerous. “The brakes were still stopping the vehicle and the pedal never once went down to the floor while applying the brakes”. She stated that she knew that the car went in for repairs on Wednesday 20 February 2002 and that Jeff’s father told her that the brakes were going to be fixed. She stated that the car was brought back to Jeff’s house by his father on 21 February 2002 and she was there. She said that Jeff’s father, Brian Williams, told her that the front brakes had been fixed and that the rear brakes were going to be fixed the following week.

    6. This witness stated that she drove the car that day to transport Jeff to a house at which he performed white ant treatment on the house. His work trailer and equipment were attached to the car at that time. On the trailer there was a pesticide tank and a pump. She stated that on the way to and from this house she found that the brakes were operating better but that they were still a little spongy. She stated that she did not have to apply as much pressure to the brake pedal to get a response from them as she did previously. She said that the brakes pulled the car to a stop even with the trailer attached. She stated that this was the last time she drove the car.

    7. Mr Brian Williams made a statement, which was received as C30a. In that statement he confirmed that it was he who took the Magna to the mechanic for repair of the front brakes. He said that he was told that the back brakes should be repaired as well and he arranged to bring the car back the following Monday (that is, the Monday following the accident). He said that the brakes were operating much better when he collected the vehicle on the Thursday before the accident.

    8. Mr Neil William Oxford provided a statement to police, which was received as Exhibit C31a. He stated that he was employed at Salisbury Auto Dismantlers at 178 Commercial Road, Salisbury as a general labourer and his duties included fixing cars. He had no formal qualifications as a motor mechanic but had about five or six years experience at working on cars. He confirmed that he performed the repair of the front brakes of the Magna on Wednesday 20 February 2002. He stated that upon inspection both front brake pads were excessively worn almost down to their metal backing. He considered that they were completely unsafe in this condition and needed immediate replacement. He stated that he correctly fitted the new pads and pushed the pistons back with a “G clamp”. Once the pads were fitted he took vehicle for a test drive and the brakes operated correctly and a good solid pedal was felt. He still felt that the brakes were not as good as they should be and so decided to check the rear brake pads also. When he inspected them he noted that they were worn down to the point where only approximately 15 percent braking material remained. He therefore decided that the rear brakes needed to be replaced also. When Brian Williams returned to collect the car Mr Oxford recommended to him that the rear pads should be replaced soon and in fact offered to replace them there and then. However Brian Williams said that the car was needed that day and that he would bring it in the following week to have the rear pads replaced.

    9. A statement was also given by Elliot Cameron McDonald of the Major Crash Investigation Unit which was received as Exhibit C34a. In his statement he said that the brake system was hydraulic and the master cylinder reserves were correctly filled with fluid resembling brake fluid. He stated:

‘The left front flexible brake hose was broken off from the left front calliper however after clamping off the brake hose I was able to obtain a brake pedal pressure. The brake pedal when depressed travelled about 4cm before a good solid feeling pedal was obtained which held pressure on both heavy and light applications and applied the brakes. The left front calliper moved freely and the disc was shiny and I could find no evidence to suggest that the brakes were not working prior to the collision. After removing the wheels I was able to inspect the brakes. I noted disc brakes were fitted to all wheels. There were 10 mm of material to the front pads and 3 mm of material to the rear pads. I was able to operate the hand brake from inside the vehicle. The hand brake operated the rear wheels when applied.’

    1. Sergeant Graham England gave evidence before the Youth Court and an account of that evidence is contained in the reasons for decision of Senior Judge Moss. He gave evidence based on measurements taken by him of the damage to the vehicle and examination of skid marks at the accident scene. Using calculations intended to determine the amount of energy used to result in the damage measured to the vehicle he was able to provide an opinion as to the speed of the vehicle prior to the collision. He told Senior Judge Moss that the speed of the Magna immediately prior to the impact was in his opinion within the range of 76 to 92 kilometres per hour.

    2. Senior Judge Moss’ reasons for decision contain an account of evidence given by Mr William Potts. Mr Potts is an engineer with experience in fault finding within braking systems. He carried out an examination of the wreck of the Magna car. An account of the method used by the mechanic who repaired the brakes, Mr Oxford, in replacing the front disk pads was put to Mr Potts. Mr Potts stated that two aspects of Mr Oxford’s methodology were of interest to him. He was surprised in the first instance that there was no bleeding of the brake system when the pistons were pushed back in order to make room for the new pads. The second concern was that the seal surrounding the pistons tends to wear together creating a complete seal. Once the piston is in a different position in the seal there will be a period when the seal is not complete because the piston and the seal have not yet worn together. In this circumstance, air can enter into the brake lines and the brakes may become spongy. This would be noticeable to the driver and the brakes could become progressively less efficient until such time as there was a complete brake failure. Mr Potts gave an opinion that the brakes may have seemed satisfactory immediately after the new brake pads had been fitted, but that with progressive driving and more air entering the braking system the brakes could become less efficient.

    3. Mr Potts also gave evidence as to the likely speed of the vehicle immediately prior to crash. His opinion was that the crush depth would be greater in this instance because there were five people in the car and it was fully laden. This meant that the energy to be dissipated at the time of the collision was greater than if there had only been one driver in the vehicle. Mr Potts considered that a speed of approximately 60 kilometres was more likely to have been the speed of the vehicle at the time of the impact.

    4. A statement was taken from the young male driver of the vehicle who was 15 years old at the time of the accident. The statement was made under caution. The driver stated that he went to the address where the Magna was that evening for a party. He was with three friends including Adam Sloan. At the party there were a number of people his age and only one adult, Jeff Williams, who was the owner of the car. At some stage Mr Williams wanted to go and get some alcohol. Mr Williams got into the front passenger seat and another young male got into the driver’s seat. Two other young people together with Adam Sloan got into the back seat.

    5. The young person who was driving reversed the vehicle only about car length and then got out, as he did not really want to drive. The driver himself then got into the driver’s seat, reversed the vehicle out of the driveway and stopped. When he went to stop the brake pedal went right to the floor but the car eventually stopped. The driver thought about getting out at that time because of the brakes but was convinced to continue by his friends in the back seat. He then drove slowly to a liquor shop near Bi Lo on Bolivar Road and there used a concrete barrier at the end of the parking bay to stop the car. Jeff Williams then got out of the car and bought a carton of Strongbow.

    6. Jeff Williams returned to the car and got into the back seat in the centre and Adam got into the front passenger seat. The driver then started to drive back towards 200 Whites Road via side streets. He stopped about half way back because Adam Sloan wanted to have a drive. Adam drove only a short distance before stopping because the brakes were not working. The driver then continued to drive from there because he thought he knew the route and the car well enough to make it back to the house.

    7. As he was travelling along Camelot Drive he was, according to his statement, doing about 60 kilometres per hour and when he was about 50 metres from Whites Road, he pushed the brake pedal hard to the floor. He stated the car continued to travel at speed only slowing to about 50 kilometres per hour before he reached the intersection. His right foot was still hard on the brake pedal. He tried to turn left but crossed the road and mounted the footpath. He took his foot off the brake, as he knew it wasn’t doing anything and the front left of the car then collided head on into a tree.

    8. The driver stated that he blacked out momentarily because his head had hit the windscreen. The seat belt was on but it had popped off during the crash. He got out via the driver’s side window, ran inside a nearby house to wash his face of blood, and then went back to the car. He went to the front passenger side and saw Adam Sloan who was trapped in the car but was talking. He then heard that the police were on their way so he left because he thought he would be arrested.

    9. The driver admitted that he knew that the faster the car went, the longer it would take to stop. He stated that he had never been to Jeff Williams’ house before nor had he ever driven the vehicle before. His only driving experience to that date was in his father’s car up and down the driveway.

    10. The Senior Judge of the Youth Court heard the witnesses referred to above, and others as well. On the basis of all of the evidence he heard, the Senior Judge made the following findings of fact:

‘1. At the time of the accident on the 22nd of February, 2002 the driver of the vehicle was fifteen years old.

2. The driver had no drivers licence and had never driven a car on a road prior to the date of the accident.

3. The brakes on the Magna were faulty. It is not possible to say how greatly they had deteriorated, but I am completely satisfied that the brakes did not stop the vehicle within safe parameters.

4. The driver of the vehicle knew that the brakes were faulty and he discovered this during the journey from Jeff Williams’ house to the Bi-Lo supermarket.

5. The driver continued to drive knowing that the brakes were faulty.

6. The driver approached Whites Road down Camelot Drive knowing that he was approaching a busy intersection.

7. The driver approached Whites Road at a speed of at least 60 kph.

8. The driver attempted to apply the brakes but the vehicle did not slow down.

9. The vehicle was travelling too fast for the driver to attempt to turn into Whites Road and the vehicle travelled directly across Whites Road and crashed into the tree.

10. Adam Sloan was killed as a result of injuries which he received in the accident.

11. Jeffery Williams and another young passenger in the vehicle each received grievous injuries as a result of the accident.

12. The young driver was driving in a reckless and dangerous manner.

13. If the driver believed that his driving was not dangerous, than that belief was unreasonable.'

    1. The evidence put before the Coroner’s Court about the collision is to the same effect as that before the learned Senior Judge, except that it was in documentary form. Having considered the documentary material admitted in evidence at the Inquest, I respectfully agree with the findings made by the Senior Judge.

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