Inquest into the death of Tristian Jaemes Frahm

CORONERS COURT OF QUEENSLAND FINDINGS OF INQUEST CITATION: Inquest into the death of Tristian Jaemes Frahm TITLE OF COURT: Coroners Court

JURISDICTION: BRISBANE FILE NO(s): 2021/5271 DELIVERED ON: 15 October 2025 DELIVERED AT: Brisbane HEARING DATE(s): 2 – 3 June 2025 FINDINGS OF: Ainslie Kirkegaard, Coroner CATCHWORDS: Coroners: inquest, child death, brown snake envenomation, snakebite management

REPRESENTATION: Counsel Assisting: Ms Sarah Ford Ms Samantha Skerritt and Ms Ms Kate Greenwood, instructed by Shanade Thorley: Aboriginal and Torres Strait Islander Legal Service.

Mr Kerrod Frahm: Mr Andrew Bale of A W Bale and Son Solicitors.

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Contents Was it reasonable for the adults to discount the possibility of snakebite at

Introduction

1. Tristian Jaemes Frahm was an 11 year old boy who passed unexpectedly at his family’s bush block in Vellacott Lane, Murgon on 21 November 2021.

2. Coronial autopsy revealed Tristian died from extensive internal bleeding due to brown snake envenomation. Brown snake venom can cause a venom induced consumption coagulopathy (VICC) which can lead to profound anticoagulation meaning the blood cannot clot normally. Major haemorrhage is rare in snakebite, occurring only in 3% of brown snake envenomations.

3. Tristian was in the care of his father, Kerrod Frahm, when he passed. Mr Frahm was charged with and committed to stand trial for manslaughter in respect of Tristian’s passing. The charge against him was discontinued on 12 April 2024.

4. Tristian was a First Nations boy with connections to the Wakka Wakka and Gunggari people. His maternal family describe his connection to his Aboriginal heritage as having ‘shone through his love for dancing, his spirituality, and his natural rhythm with the world around him’. He is loved and remembered by his family as a free spirit and a loving, caring soul with a deep love for animals and being in nature. He was a devoted big brother and incredibly helpful with babies and younger children, including at school.

He was full of energy and adventure and brought joy ‘cracking everyone up with his endless funny moments’.

5. Tristian’s passing may have been prevented had he received medical attention when it was initially thought he may have been bitten by a snake on 20 November 2021. The circumstances in which he passed demonstrate the importance of taking even the possibility of snakebite seriously by immediately phoning 000, applying a pressure bandage to the suspected bite site, keeping the person still and seeking urgent medical attention.

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6. The inquest examined:

(a) the circumstances surrounding Tristian’s passing;

(b) public awareness of the signs and symptoms of snake envenomation and the first aid to be applied for a suspected snakebite; and

(c) whether there are any recommendations that can be made which could prevent deaths from happening in similar circumstances in the future.

7. My role as Coroner is to independently investigate Tristian’s death to determine his identity, the medical cause of his death and when, where and how he died. The Coroners Act 2003 prevents me from determining criminal or civil liability for his death.

8. The relevant standard of proof is that of the balance of probabilities, with reference to the Briginshaw standard1. Accordingly, the more significant the issue for determination, the clearer and more persuasive the evidence must be for me to be sufficiently satisfied on the balance of probabilities that the issue has been proven.

9. I may, where appropriate, comment on matters connected with Tristian’s passing and make preventative recommendations concerning public health and safety, the administration of justice or ways to prevent deaths from happening in similar circumstances in future

10. I am obliged to provide information to the Director of Public Prosecutions if from information obtained while investigating Tristian’s passing, I reasonably suspect a person has committed an indictable offence.

The property at 17 Vellacott Lane, Murgon (‘the property’)

11. Mr Frahm and his partner purchased the 50 acre property from his uncle earlier in 2021. Mr Frahm, his partner, and their respective children, including Tristian, spent most weekends out at the property, clearing and tidying it up.

1 Briginshaw v Briginshaw (138) 60 CLR 336.

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12. The layout of the property, its natural environment, its telecommunications accessibility, and proximity to the Murgon township are important to understanding the circumstances in which Tristian passed.

13. The property was surrounded by dense bushland. There is a creek running south of the property and a dam. Mr Frahm had cleared a flat area near an existing shed and installed a donga comprising three bedrooms and a bathroom. There was also an old outhouse, rainwater tanks, camp kitchen and fire pit in this area. There were mown paths creating walking tracks from the cleared area to other parts of the property including the creek.

14. While at the property, Tristian, his brother K1, and his stepbrother K2 enjoyed cook ups and bonfires, swimming in the dam, kicking the football around, going out into the paddocks and riding a ride-on mower to check out the creek. The ride-on mower was modified to disengage the blades.

The boys were allowed to double on it, with one sitting on the bonnet while the other drove.

15. The property is approximately 10 minutes’ drive to and from the Murgon town centre and around eight minutes’ drive to the Murgon Hospital.

16. There was no mobile phone reception, landline, internet connection or textmessage capability at the property.

17. Witness accounts regarding where mobile reception could be obtained varied between first becoming available at the ‘top’ of the driveway on Barambah Road to between 500 metres and three kilometres from the end of the driveway.

Prevalence of snakes at the property

18. Mr Frahm was very familiar with the property having visited it many times over the course of his life. He had seen both brown snakes and red-bellied black snakes out there over the years. He was aware of how highly venomous Eastern brown snakes are compared to other snake species. He said he was not aware of anyone having been bitten by a snake at the property previously.

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19. There was no first aid kit at the property.

20. Mr Frahm told the inquest he had never spoken to the boys about snakebites.

21. The Frahm boys had access to boots and long pants purchased for them by their mother’s family.

22. Kerrod completed a first aid course through his employer in 2018. The course assessment included a section on first aid for snakebites which he answered correctly.

Expert evidence about how to recognise and respond to snakebite

23. The inquest was informed by expert advice and opinion from two emergency physicians. Dr Mark Little and Associate Professor Katherine Isoardi, regarding the appearance of snakebite, the signs and symptoms of snake envenomation and the first aid to be applied. Both witnesses are also clinical toxicologists with a particular interest in snake envenomation.

24. Between 2001 and 2021, there were 47 venomous snake-related deaths in Australia, 18 of which occurred in Queensland. Snake-related deaths are most often caused by brown snake envenomation. While these statistics do not suggest a prevalence of deaths caused by snake envenomation, another child died from snakebite envenomation in Queensland in 2024.

25. The experts’ key message is for people to take even the possibility of snakebite seriously, apply the correct first aid and seek medical attention immediately, regardless of the type of snake or the person’s symptoms.

26. I have considered evidence about observations of Tristian’s condition and the actions of the three adults present at the property over 20-21 November 2021 with reference to the experts’ advice about snakebite marks, the body’s physiological response to snake envenomation and the appropriate first aid response to possible snakebite.

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What do snakebite marks look like?

27. Brown snake fangs are not very large meaning their bite marks can be easily missed. They can leave fang or puncture marks, a normal looking scratch or no obvious mark at all. Associate Professor Isoardi references a series of 136 patients with definite brown snake envenomation in which there were no fang marks appreciated in 28% of those cases.

28. Forensic pathologist Dr Christopher Day explained, with reference to autopsy photographs, that there were two small scratch type marks on Tristian’s right ankle (being the marks made by the snake’s fangs) which he says would have appeared immediately. These marks were surrounded by punctate type bruising likely from systemic effects of envenomation which would have developed over time.

29. The experts explained that there are two types of venomous snakebite – dry bites (where venom is not released into the person’s body) and venomous bites. There is no way of knowing whether a bite is dry or venomous without undertaking specific medical investigations.

What are the signs and symptoms of snake envenomation?

30. The experts explained how specific and/or non-specific symptoms can appear after a person sustains a venomous snakebite.

31. Specific symptoms can include a collapse or faint, bleeding (including internal bleeding) and cardiac arrest. Associate Professor Isoardi told the inquest that in around 37% of brown snake envenomation cases, there is an early collapse probably due to the secondary release of substances which dilate blood vessels causing hypotension. Early collapse usually occurs within one hour of the bite if no pressure bandage is applied to the bite site. She explained how a person may just be very hypotensive and lightheaded but not pass out. Alternatively, a person can have a cardiac arrest requiring resuscitation during a period of early collapse.

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32. Non-specific symptoms can include nausea, vomiting, headaches, abdominal pain, and diarrhoea. Dr Little explained it is possible for a person’s non-specific symptoms to settle down and then reappear from time to time. Insofar as children are concerned, they are particularly resilient and can look reasonably well until something catastrophic happens.

What first aid should be applied for possible snakebite?

33. The experts agree that regardless of the person’s symptoms (or absence thereof), the first step is to phone 000, apply a pressure bandage and keep the person still. Immobilisation is crucial to slowing the spread of venom.

Snake envenomation can only be confirmed with specific medical tests, so it is important to seek medical attention immediately.

The events of 20-21 November 2021

34. Tristian passed while visiting the property with Mr Frahm, his younger brother K1 and his stepbrother K2 to celebrate K2’s 12th birthday. Mr Frahm’s partner (K2’s mother) was with them on Friday, 19 November 2021 but was taken to hospital after injuring her ankle at the property overnight.

Mr Frahm had driven her and the boys back to Murgon where they met his mother Sharon Frahm, who drove Mr Frahm’s partner to the Murgon Hospital.

35. Mr Frahm told police he had taken a 30 pack of Carlton Dry beer and a 10 pack of Wild Turkey 101 pre-mix cans on Friday 19 November 2021. He and his partner consumed some of the beers that afternoon and evening.

36. Mr Frahm and the three boys returned to the property at around 11:30am the following morning, 20 November 2021. The boys spent time helping Mr Frahm cut wood for the bonfire and playing in the dam. K2’s aunty, Rochelle Dorman and her partner, Jacob Bryant, joined them at around 2:00pm. Mr Bryant brought some beers with him.

Tristian’s fall from the ride-on mower

37. During the afternoon, everyone was sitting around the fire while Mr Frahm was preparing a spit roast for dinner.

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38. At around 3:30pm, Tristian and K2 asked and were allowed to take the rideon mower down to the creek. Tristian was sitting on the bonnet while K2 drove. They were wearing shorts and no shoes at this time. Mr Frahm did not consider this to be unsafe. He told the inquest they were going down to the creek for a quick swim and never wore shoes when riding the mower.

39. K2 told police that Tristian fell off the mower ‘just at the end of the driveway’.

He said Tristian told him he had been bitten by a snake, so K2 jumped off the mower straight away to check if there was a snake but all he saw was a stick. He says he told Tristian he must have stood on a stick, thinking that’s what made Tristian think he had been bitten by a snake. K2 described Tristian acting ‘really different’, lying on the ground for about five minutes, not answering or saying ‘go away, go away’, so K2 rode the mower back to the adults for help. This is estimated to have occurred approximately 20 minutes after the two boys left on the mower.

40. Mr Frahm and K2 rode the mower back to Tristian. There is evidence indicating K1 ran back with them. Mr Frahm had to lift Tristian up off the ground onto the mower.

41. There is no dispute Tristian was not his normal self when Mr Frahm brought him back to the group. He appeared ‘dazed’ or concussed. He said he felt sick in the belly and wanted to vomit. Mr Frahm leaned Tristian up against a car. While he could stand up against the car, he was swaying from side to side. He was slurring his words. He walked ‘like an intoxicated person’.

He vomited.

42. The experts agree these symptoms likely represented a period of early collapse after snakebite, suggesting Tristian was bitten either while he was riding on the mower or after he fell off.

Was Mr Frahm privy to discussions about a possible snakebite?

43. Between initial versions given to police, evidence given at the committal hearing in November 2023 and during the inquest, there are multiple differing accounts about what happened when Tristian returned on the mower with Mr Frahm.

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44. There is no dispute that either or both the other boys raised the possibility of snakebite, leading to the adults checking Tristian for bite marks and finding none. Mr Bryant recalls K1 was trying to say Tristian was bitten by a snake, but K2 was talking over the top of him, cutting him off by saying “no, it wasn’t a snake, it was just a stick”. Mr Bryant said the two boys kept talking over the top of everyone. Mr Bryant asked Tristian where he had been bitten. Tristian did not answer but K1 said “I think he got bitten on the leg”. One of the boys suggested Tristian had stolen some cans of alcohol from the esky. This led to the adults discounting a snakebite in favour of Tristian being affected by alcohol.

45. The key issue is whether Mr Frahm was aware of the possibility of snakebite and participated in that sequence of events before Tristian went to lie down in the donga.

46. The weight of evidence supports a finding that Mr Frahm was aware of and checked Tristian with knowledge of the possibility of snakebite because:

(a) K1 told police Tristian had told Mr Frahm he thought he had been bitten by a snake, but Mr Frahm said words to the effect of “not even”.

(b) the version given by both boys to police places Mr Frahm present during discussion about whether Tristian was bitten by a snake.

(c) Mr Bryant’s evidence to police, at the committal hearing, and during the inquest consistently places all three adults present when the boys were talking about snakebite and all three of them were checking Tristian for bite marks. I place significant weight on the consistency of his evidence in this regard.

(d) Ms Dorman initially told police Mr Frahm was present and asked Tristian where he had been bitten.

(e) in a pretext call on 22 November 2021, Mr Frahm told Tristian’s mother K1 “..goes he reckons he got bitten by a snake but he was only gammin it was only a stick that hit him in the leg. And we had a look at him when he come over when he came back from going down to the creek.” Findings of the inquest into the death of Tristian Jaemes Frahm Page 10 of 22

(f) on 23 November 2021, Mr Frahm told police that after retrieving Tristian from the paddock, “I asked him what happened and he just (ui) himself and just fell off. I think he bumped his head or something, I’m not sure.

Cause I know I didn’t see any marks on him and they said, oh he, he got, a snake bit him. But then they’re like, oh no only gamming, it was a stick.

So we checked him all over and…checked his legs if there’s any bites or anything, and I couldn’t see any mark, or anything on him.” When asked where he checked Tristian, Mr Frahm said “His legs, his arms, and pretty much his whole body.”

(g) Mr Frahm told the inquest he checked Tristian for marks twice, once before taking Tristian to the shower and again while he was in the shower.

47. Ms Dorman’s evidence changed during cross examination at the committal hearing, suggesting Mr Frahm was elsewhere tending the fire. Mr Frahm provided an entirely different and self-serving account at the inquest. He said he was checking the fire after putting the mower away. He maintains nobody said anything to him about Tristian having been bitten by a snake until after Tristian’s passing. When pressed on the issue, Mr Frahm’s answers included he ‘could not recall’, it was ‘hard to talk about’, ‘hard to answer’, he vaguely remembered speaking to police and what he told them was a bit of what he remembered and what others had told him. I do not accept this significant change in their respective evidence years down the track. It is inconceivable that no one mentioned the possibility of a snakebite to the child’s parent at any time prior to his passing, particularly when he continued to exhibit symptoms during the afternoon and overnight.

Was it reasonable for the adults to discount the possibility of snakebite at this time?

48. All three adults say they observed nothing on Tristian’s body resembling what they understood a snakebite to look like, namely distinct bite/fang/puncture marks and/or blood. None of them had previously seen a person with a snakebite nor were they aware that snakebites can appear as a scratch on the skin without any blood or show no injury at all.

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49. Further, Tristian had dirt, mud, grass, scratches, and bruises on his body after helping with the firewood and playing in the dam.

50. The experts agree it is plausible the adults did not see any bite marks on him in this context.

51. I accept that the absence of obvious puncture marks contributed to the adults discounting snakebite as the cause of Tristian’s presentation. It is possible that had the three adults known a snakebite can appear as a mere scratch, they may not have discounted the possibility of snakebite so readily.

52. However, the evidence clearly indicates it was the absence of obvious bite marks in combination with information that Tristian had been sneaking cans of alcohol from the esky that led the adults to attribute his condition to the effects of alcohol rather than snake envenomation. This is despite none of the adults having seen Tristian take or consume alcohol that day.

53. Mr Bryant and Ms Dorman both say they were told the boys had taken beers.

This information was significant in quickly changing their minds about what they were being told about Tristian being bitten by a snake. Ms Dorman told the inquest she thought the boys may have been telling lies about the snake to cover up Tristian being ‘a bit tipsy’.

54. Mr Bryant recalls Mr Frahm saying words to the effect of “If you’ve been sneaking my beers then go lay down you dickhead”.

55. Mr Frahm was adamant Tristian had skolled three cans of Wild Turkey (containing 6.5% alcohol each). It was put to him it was implausible that an 11 year old child could drink that amount of alcohol between 11:30am and 4:00pm. Mr Frahm said it was ‘quite possible’ and that’s why he thought Tristian was sick and vomiting. He claimed Tristian (and the other boys) used to try and have a sip of the adults’ alcohol at home.

56. Tristian’s mother later told police that K1 told her Mr Frahm had allowed the three boys to drink Wild Turkey 101s, but Sharon Frahm told K1 and K2 to lie to police and say they had stolen them. When asked by police whether anyone had told them not to say anything about what had happened, K1 Findings of the inquest into the death of Tristian Jaemes Frahm Page 12 of 22

said “I don’t think so, no” and K2 said “no”. The allegation was not put to Mrs Frahm during her evidence, so I make no finding about this suggestion.

57. It can never be known to what extent Tristian was affected by alcohol, if at all, at that time. Toxicology performed on postmortem samples (femoral and subclavian blood, urine, stomach contents and vitreous humour) received on 22 November 2021 detected no alcohol. Dr Day explained that while this shows Tristian did not have any alcohol in his system when he passed, it is possible he could have entirely metabolised any alcohol consumed earlier.

58. Putting the possibility of snakebite to one side, Dr Little considered the history of a fall from the ride-on mower, nausea, vomiting and abdominal pain could all be consistent with either alcohol and/or head strike with a mild concussion. He could see how the adults may have interpreted the suggestion Tristian had consumed alcohol as an explanation for not only his symptoms but also how he came off the mower and potentially banged his head.

59. Associate Professor Isoardi agreed Tristian’s symptoms at that time were non-specific and could have indicated an illness or something other than a snakebite. She would not expect a member of the public to be able to identify snake envenomation when even health care professionals can have difficulty determining whether a person has been envenomed.

60. On this basis, I find it was not unreasonable for three adults who have never seen a snakebite before to discount the possibility of snakebite in the absence of obvious puncture marks and with other plausible explanations for Tristian’s non-specific symptoms at this time.

Tristian’s condition during the afternoon and into the night

61. After Mr Frahm washed him off in the shower, Tristian went to lie down in the donga. Mr Bryant says Mr Frahm told Tristian to lie down and ‘sleep it off’. The other boys took Tristian to the donga.

62. Mr Bryant and Ms Dorman told the inquest there was no discussion amongst the three adults about monitoring Tristian or phoning 000 or taking him to hospital as a precaution. Mr Frahm told the inquest he was checking on Findings of the inquest into the death of Tristian Jaemes Frahm Page 13 of 22

Tristian about every 20 minutes though he did not tell police this when they first spoke with him. He suggests this was ‘probably because they never asked me’.

63. Dr Little felt it was reasonable for a child who may be minorly concussed to ‘lie down and sleep it off’ provided the child was being woken and checked to monitor their symptoms every 30 to 60 minutes. Associate Professor Isoardi would expect a reasonable adult who was concerned about concussion and where their child was ‘not right and vomiting’ to seek medical assistance. She felt that ‘sleeping it off’ if someone had a bit of alcohol would be quite reasonable.

64. Over the following ten hours, Tristian was observed to:

(a) have vomited in the donga during the afternoon – Mr Frahm changed and washed his bedding.

(b) be awake.

(c) complain of having ‘a pain the belly’.

(d) say he was tired and not feeling well during the afternoon.

(e) walk independently from the donga to the fire where he had something to drink and sat with Ms Dorman and the other boys for a while. He complained his mouth tasted weird from throwing up – Ms Dorman says Tristian seemed ‘normal’ at this time.

(f) say he was too sick to eat when the boys took him some dinner.

(g) speak briefly with Ms Dorman at around 8:00pm at which time he seemed ‘perfectly fine’.

(h) complain of stomach pain, ask for water, and then fall out of the door of the donga onto the ground outside and vomit sometime between 10:00pm and midnight.

(i) exhibit significant pain overnight, drink some water, leave the donga to lie down on the grass and at some stage ask the boys to get an adult.

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(j) be sitting upright in the doorway of his room, looking at the ground and up at the sky and wave to Ms Dorman as she went to the outhouse at around 2:00am – Ms Dorman says he looked ‘perfectly fine’ at this time.

65. Mr Frahm and Mr Bryant were drinking that evening. Ms Dorman was sober as she was pregnant. She went to bed at around 8:00pm. Mr Bryant went to bed sometime around midnight. Mr Frahm was asleep on a couch at the shed when K1 went to him for help during the night but K1 could not wake him. Mr Frahm woke later and went to his room in the donga at which time he says the boys were all sleeping.

66. Sometime before 2:00am, K1 sought help from Ms Dorman telling her Tristian felt sick in the stomach, had vomited, and needed help. K2 told police the boys kept telling her to come out because Tristian was feeling ‘really bad’. She says she didn’t think much of it because K1 did not sound panicked, and she thought Tristian was just ‘grog sick’. She did not appreciate the significance of Tristian’s ongoing symptoms and did not check on him herself. She told K1 to give him some water and lie him on his side. She then went back to sleep.

67. K1 told police he put Tristian on his side, gave him a pillow and a blanket and stayed with him out on the grass for some time before going to sleep in Mr Frahm’s car.

68. Mr Bryant told police he woke at around 5:00am and vomited outside the donga. He had some water and went back to sleep. He did not notice anyone outside the donga at this time.

69. K2 told police he saw Tristian sitting outside the donga when woke at around 6:00am to go to the toilet. He claims Tristian spoke to him and seemed fine.

70. Mr Bryant and Ms Dorman woke sometime between 7:30am and just before 8:00am. They saw Tristian lying on the ground outside the donga. They walked past him down to the fire pit. Mr Bryant assumed Tristian was asleep and Ms Dorman thought nothing of it.

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71. While they were sitting at the fire, K1 approached them crying. He told them Tristian was not breathing or moving, he had thrown up overnight and had been sitting outside the donga calling out to the boys for help. As Mr Bryant started walking towards the donga, he saw Mr Frahm come out of his room, give Tristian a small shove and try to wake him. Tristian was stiff and cold to touch. This is when Mr Frahm realised Tristian had passed.

72. Associate Professor Isoardi explained how a lot of the early symptoms that can happen with snake envenomation don’t necessarily reflect a life threatening illness or being unwell. A person maintains their sensorium meaning they can still move around, sit up and do things normally because the venom does not affect their brain.

73. The experts both identified Tristian’s vomiting as an early non-specific symptom of envenomation. The evidence suggests Tristian’s complaints of abdominal pain became more prominent as time passed overnight. Both experts suggested this may have reflected increasing intra-abdominal and retroperitoneal haemorrhage associated with VICC. Even so, Associate Professor Isoardi suggested that by 2:00am on 21 November 2021 while Tristian perhaps would not have seemed ‘perfectly fine’, he might have appeared ‘not severely unwell’.

74. Dr Little agreed with Associate Professor Isoardi’s estimate of Tristian’s passing sometime between 10 and 16 hours after envenomation. Dr Little explained that internal bleeding can occur many hours after a snakebite. He believes this is what happened for Tristian. Noting Tristian was cold and stiff when Mr Frahm found him, it is likely he passed sometime between after Ms Dorman last saw him alive at around 2:00am and around 7:00am.

75. It was only K1 and to some extent K2, who recognised that Tristian was unwell and needed help as the night wore on. Tragically K1’s repeated efforts to obtain help for his brother were thwarted by Mr Frahm being soundly asleep and Ms Dorman’s continued assumption Tristian was suffering the effects of alcohol. I acknowledge K1’s deep worry for his brother and his helplessness in this distressing situation. He provided comfort for Tristian as best he could.

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What happened after Tristian was found to have passed?

76. Rather than phoning 000, Mr Frahm told Mr Bryant to go and get Sharon Frahm. He told the inquest this was the first thing he thought to do because he was panicked and shocked. He said he sent the couple to let his mother know what was happening and get somebody to call the ambulance or the police to come out.

77. The couple drove to the Frahm residence in Murgon. Mr Frahm’s parents were not home so they drove to Ms Dorman’s parents’ house. Her brother told them to phone an ambulance. Mr Bryant thought someone was going to phone 000 but he was not certain whether that eventuated.

78. Data from Sharon Frahm’s phone shows she received a call at 8:48am from a phone number registered to Ms Dorman’s father. Sharon Frahm told the inquest she spoke with Ms Dorman’s brother who told her Tristian was not breathing. She says she told him to tell her son to do CPR on Tristian.

79. Meanwhile Mr Frahm decided to drive into town, taking the boys with him, leaving Tristian’s body unattended. He phoned his mother at 8:51am while driving into town. This was approximately 30 minutes after Mr Bryant and Ms Dorman left the property. Sharon Frahm says her son was hysterical, and she could not make sense of anything he was saying. She and her husband were driving towards the property at this time.

80. CCTV footage obtained by police shows Mr Frahm’s parents arriving at Murgon Paint and Panel before Mr Frahm arrived. Mr Frahm told his mother Tristian had passed. Sharon Frahm phoned 000 at 8:55am.

81. Police officers arrived at the property at around 9:05am, followed by paramedics at 9:28am. Tristian was found deceased, lying on his back on under a sleeping bag on the ground outside the donga. There were two marks on Tristian’s right ankle consistent with a snakebite. There were three patches of vomit within 20 metres of Tristian, the closest being within 50 centimetres.

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Was Tristian’s death preventable?

82. Potentially yes. The experts agree that had Tristian received early medical attention, he would more likely than not have survived. Had he presented to hospital after his initial collapse, Tristian would have received treatment including thorough medical examination which may have identified the bite marks, a pressure bandage to the bite site, intravenous access, and tests to check for evidence of coagulopathy, access to antivenom, treatment to reverse coagulopathy and monitoring and intervention for internal bleeding.

83. The three adults did not seek medical attention for Tristian because in the absence of obvious puncture marks, they believed his symptoms were alcohol related.

84. They were each capable of seeking medical attention for Tristian out of precaution by accessing phone reception and phoning 000 or driving him to the Murgon Hospital. Mr Frahm told the court he ‘wasn’t drunk at all’ and the amount of alcohol he consumed over the course of 20 November 2021 would not have stopped him driving in an emergency. He said he had consumed the same amount of alcohol as the previous night when he drove his partner into town so she could be taken to hospital. Ms Dorman was sober and although she did not have a driver’s licence, she told the court she could drive in the case of an emergency.

85. It is important to consider the evidence prospectively. Tristian died from an extremely rare complication of brown snake envenomation. Having regard to the experts’ advice about the non-specific nature of Tristian’s early symptoms in this context, it is understandable why the adults discounted and did not reassess the possibility of snakebite envenomation as the cause for his symptoms. It is only with the benefit of hindsight that their actions and inaction can be considered lacking. This is why I have not made any referrals to the Director of Public Prosecutions in relation to Tristian’s death.

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Findings required by s. 45 Identity of the deceased – Tristian Jaemes Frahm How he died – Tristian Jaemes Frahm died from a rare complication of brown snake envenomation for which he did not receive medical attention.

Three adults, including Tristian’s father Kerrod Frahm, received information that Tristian may have been bitten by a snake. They checked him for bite marks but in the absence of any obvious puncture marks, and on being told Tristian had earlier consumed alcohol, they attributed his non-specific symptoms to the effects of alcohol.

This is why they did not seek medical attention for him. Tristian’s death may have been prevented had he received early medical attention.

Place of death – 17 Vellacott Lane MURGON QLD 4605

AUSTRALIA Date of death– 21/11/2021 Cause of death – 1(a) Brown snake envenomation.

Comments and recommendations Availability of snakebite awareness information for the public

86. Tristian’s passing demonstrates the importance of promoting and reinforcing public awareness and understanding of the appearance of snakebite, recognising the signs and symptoms of snake envenomation and the need for urgent medical attention by immediately phoning 000, applying a pressure bandage and keeping the person still, even if there is a just the possibility of snakebite.

Findings of the inquest into the death of Tristian Jaemes Frahm Page 19 of 22

87. The Queensland Ambulance Service2, Children’s Health Queensland3 and the Queensland Poisons Information Centre4 each publish snakebite first aid guidelines and awareness content. These are supported by the Australian and New Zealand Committee on Resuscitation guidelines.5

88. The Queensland Ambulance Service also delivers community education programs including snakebite management content targeting school age children and adults.6 It also delivers regular public health messaging in the form of free to air media broadcasts, radio broadcasts and social media posts.

89. While there may be a reasonable saturation of information available to the public about snakebite management, it does not necessarily follow this information is widely known by the public. Of the three adults, only Mr Bryant indicated some awareness about applying a pressure bandage and none of them indicated any awareness of the importance of immobilisation.

This is despite Mr Frahm having correctly answered the snakebite management question in a first aid assessment some years earlier.

90. In his evidence, Dr Little referenced a study undertaken in Darwin which found only about 20% of people bitten by snakes had received appropriate first aid prior to hospital. In his opinion, there is a need to improve public awareness and understanding of the correct first aid response to snakebite.

91. The Queensland Ambulance Service is to be commended for its significant efforts to educate children about snakebite first aid through its school-based education programs. As for the adult population, I acknowledge that no matter the intensity and frequency of public awareness campaigns, not everyone will benefit from them or indeed, pay attention to them. The onus rests with individuals to educate and protect themselves and those in their care. Let this be Tristian’s legacy.

2 2022_DCPM_021222.pdf 3 Snake Sense: Understanding of and first aid for snakebites | Children's Health Queensland; CHQ-GDL-00725 Emergency Management of Snakebites in Children 4 Snakebites | Queensland Poisons Information Centre 5 guideline-9-4-1-first-aid-management-of-australian-snake-bite-279.pdf 6 Community education and awareness | Queensland Ambulance Service Findings of the inquest into the death of Tristian Jaemes Frahm Page 20 of 22

I close the inquest.

Ainslie Kirkegaard Coroner

BRISBANE Findings of the inquest into the death of Tristian Jaemes Frahm Page 21 of 22