Coroner's Finding: Roberts Henry Arthur

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Olivia McTaggart, Coroner, having investigated the death of Henry Arthur Roberts Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Henry Arthur Roberts; b) Mr Roberts died as a result of injuries sustained when he was overrun by a tractor in the circumstances described in this finding; c) The cause of death was blunt trauma of the head and chest; and d) Mr Roberts died on 16 March 2020 at Huonville, Tasmania.

In making the above findings, I have had regard to the evidence gained in the comprehensive investigation into Mr Henry Arthur Roberts’ death. The evidence includes:  The Police Report of Death;  An opinion of the forensic pathologist who conducted the autopsy;  Affidavit of Patricia Mary Roberts, wife of Mr Roberts;  Affidavits from neighbours;  Affidavits of three Tasmania Police crash investigators, who reconstructed the incident;  Affidavits from attending and investigating police officers;  Affidavit of the Transport Inspector, who examined the tractor after the death;  Medical records and reports; and  Forensic and photographic evidence.

Background Henry “Harry” Arthur Roberts was born in Tasmania on 8 April 1932 to Elizabeth Lillian Roberts and Gordon Richard Roberts. He was 87 years of age at the time of his death and is survived by his wife and six children.

Throughout the course of his life, Mr Roberts worked in a variety of jobs. He operated an apple orchard with his wife until 1977 and later, worked as a shop proprietor and school bus driver. In 1994 Mr and Mrs Roberts were granted their own school bus run from Dover to Hobart.

Mr and Mrs Roberts had owned and operated their farming property in Huonville for many years. In his latter years, Mr Roberts farmed up to 50 head of cattle and leased out a potato paddock.

Mr Roberts had an extensive history of health conditions. These included prostate cancer, heart conditions (for which he had had coronary artery bypass surgery and a pacemaker fitted) and bowel cancer. In 2013 he was diagnosed with leukaemia and suffered that illness until he died. Mr Roberts’ vision was also severely impaired by macular degeneration. In 2014 his ophthalmologist advised that he was no longer fit for commercial driving, was on the “borderline” for driving a private vehicle and should no longer drive his tractor on the open road. He was also almost completely deaf and was reliant on hearing aids at the time of his death. Mr. Roberts’ medical history also reveals that, in 2015- 2016 he suffered from memory loss and mild cognitive impairment.

Despite his medical conditions and failing eyesight, Mr Roberts continued to work on the farm and drive his tractor until his death.

His wife described him as an extremely hard worker but has also described him as a “terrible risk taker” and a “daredevil”. In her affidavit she gave examples from previous years where Mr Roberts had attempted to stop a bus rolling forward by standing in front of it; being run over by a large silage bale whilst standing in front of it to stop it moving; and chasing after an out-ofcontrol tractor and getting onto it. She stated that she believed that there were many other similar incidents that Mr Roberts did not tell her about. Mrs Roberts said that, about three weeks before his death, Mr Roberts had somehow become trapped between a couple of limbs of a fallen tree which left him with wounds in the back of his leg and shin with black toes and serious bruising. Mrs Roberts said that “for the last couple of years, I thought he was likely to do something on the farm that would cause him significant injury.” Affidavit evidence provided by Mr Roberts’ neighbours indicates that they saw Mr Roberts driving his tractor on a daily basis and that he seemed competent in his ability to control it.

One neighbour indicated that, on more than one occasion, she had seen him walking behind the tractor whilst it was moving forward slowly as he removed the hay to feed the cattle.

Mr Roberts owned a 1970 Ford 3000 tractor, which he always drove for his farm duties. His son organised services and repairs on the tractor when Mr Roberts requested. His son did not believe the tractor was in a roadworthy condition, although Mr Roberts was stubborn and did not have it serviced regularly. The engine had been rebuilt in about 2015, at which time Mr Roberts’ son took steps, in the interests of safety, to ensure that it could only start in neutral and not in forward gear.

Circumstances of death On 16 March 2020, Mr Roberts had lunch and went to work on the farm. Mrs Roberts was not aware of what he was going to be doing on that day. From the scene investigation, it appears that he had been cutting wood and tidying up in his paddock opposite 19 Benders Road. He had been driving his tractor to assist with the work.

At around 3.00pm neighbours, Ms Phyllis Vos and Mr David Magor-Hampel, were in their respective gardens when they heard strange sounds coming from outside. Ms Vos heard a banging sound that sounded like a post being driven continually into the ground. When she went to investigate, she saw Mr Roberts’ tractor with the engine running but with no-one on it.

She saw that it was repeatedly moving forward and backwards against a pole.

At about the same time, Mrs Roberts was informed that there was a small fire on the property.

When she went out in her car to investigate and find her husband, she saw the tractor in the position described above, with Mr Roberts lying on the ground a short distance away with his knees bent. She called emergency services. At that time, Mr Magor-Hampel and Ms Vos were arriving on the scene and observed that Mr Roberts was still alive, breathing shallowly, with his mouth and back of his head saturated in blood. Mr Magor-Hampel turned off the tractor while Ms Vos, a Registered Nurse, assisted Mrs Roberts. Ms Vos cleared his airway and rolled him onto his side. He was not responsive and did not react to pain stimulation.

Emergency Services and police officers arrived at the scene. Police officers and members of emergency services attempted resuscitation but, at 4.52pm, it was determined that he was deceased. He was conveyed by mortuary ambulance to the mortuary at the Royal Hobart Hospital.

An autopsy was performed by forensic pathologist, Dr Donald Ritchey. At autopsy, Dr Ritchey noted that there were several traumatic injuries, both internally and externally, of the head and chest. In his opinion, Mr Roberts was likely overrun by the tractor after falling or possibly having been knocked from the vehicle by a falling tree branch. He determined the cause of

death to be blunt trauma of the head and chest with generalised atherosclerosis, advanced emphysema and chronic leukaemia as contributing factors. I accept his opinion.

On 20 March 2020, State Growth Transport Inspector, Jason Hardy, inspected the tractor. In his opinion, the tractor was in an un-roadworthy condition due to non-compliance with registration regulations. However, I am satisfied that these defects were not contributing factors in the reasons for the incident. The tractor was in a reasonable operating condition.

An analysis of the crash was completed by crash investigator, Constable Jared Gowen, who carefully examined the scene with two other crash investigators. Constable Gowen noted that the incident scene was on a sloping area next to Benders Road. The tractor was resting against a wire fence and flanked by a cluster of large eucalyptus trees. The ground at the location was covered by fallen branches and small stones. Several tyre impressions from the tractor were visible in the soil. There was also chipping to the bark of a large tree standing next to the tractor. Mr Roberts himself was positioned on the ground about 7.5m north-west of the tractor at the bottom of the embankment. A small amount of Mr Roberts’ hair was located on the underside of the left steering arm of the tractor. The tractor was found to remain in gear, with the throttle not requiring to be manually operated to maintain forward momentum. The handbrake was also found in the ‘on’ position, indicating that Mr Roberts had applied it in its final resting position.

A reconstruction of the events was undertaken by Constable Gowen and two other experienced crash investigators, Acting Sergeant Adam Hall and Senior Constable Cordwell, in order to determine the sequence of events leading to Mr Roberts’ death.

The crash investigators were not able to determine the exact sequence of events, although they concluded that Mr Roberts alighted from the tractor whilst it was still under forward momentum and, somehow, came to be in its path. He was then run over by the tractor whilst in a facedown position on the ground. Nevertheless, he was able to get up from the ground and get back on the tractor, as demonstrated by the fact that deliberate steering input was required to maintain the course of travel indicated by the tyre marks. After the tractor crashed into the fence, Mr Roberts activated the handbrake and alighted from the tractor. He then walked or stumbled to where he was found on the ground.

Comments and Recommendations Mr Roberts died at his “workplace” (as that term must be construed) of unnatural causes. As such, his death would ordinarily be required to be the subject of a public inquest pursuant to section 24 of the Coroners Act 1995. However, I have received a representation from the

senior next of kin, Mrs Patricia Roberts, under section 26A(2) of the Act, that she does not seek that an inquest be held. Further, I am satisfied that, under section 26A(3) of the Act, it is not contrary to the public interest not to hold an inquest. I have therefore decided not to do so.

I extend my appreciation to the investigating officer First Class Constable John Shaw and the three crash investigators, in particular Constable Gowen, for their thorough investigation and reports.

I convey my sincere condolences to the family and loved ones of Mr Roberts.

Dated: 26 November 2021 at Hobart Coroners Court in the State of Tasmania.

Olivia McTaggart Coroner