Deceased
ROBERTSON, TRENT NATHANIEL
Demographics
44y, male
Coroner
State Coroner Fogliani
Date of death
2018-05-27
Finding date
2020-11-20
Cause of death
head and neck injuries with terminal palliative care
AI-generated summary
Trent Robertson, 44, died from severe head and neck injuries sustained in a high-speed motorcycle crash on 27 May 2018 after evading a brief police traffic stop. Police observed him speeding at 92 km/h in a 60 km/h zone, activated lights and sirens to conduct a Vehicle Interception, then appropriately ceased pursuit after 100-150 metres when he accelerated away. Robertson continued at excessive speed (approximately 100+ km/h), lost control at a roundabout 200+ metres from the police, and was thrown from his motorcycle. Despite rapid first aid response and sophisticated trauma management at Royal Perth Hospital including ICU care, his severe injuries were unsurvivable. The coroner found police did not cause or contribute to his death—Robertson's dangerous riding while evading police was the direct cause. No medical or procedural errors were identified.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
[2020] WACOR 39 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : Rosalinda Vincenza Clorinda Fogliani, State Coroner
HEARD : 22 NOVEMBER 2019 DELIVERED : 20 NOVEMBER 2020 FILE NO/S : CORC 629 of 2018
DECEASED : ROBERTSON, TRENT NATHANIEL Catchwords: Nil Legislation: Nil Case(s) referred to in decision(s): Nil Counsel Appearing: Mr T Bishop assisted the State Coroner.
Ms M Hemsley (State Solicitor’s Office) appeared on behalf of the Western Australia Police Force.
[2020] WACOR 39 Coroners Act 1996 (Section 26(1))
RECORD OF INVESTIGATION INTO DEATH I, Rosalinda Vincenza Clorinda Fogliani, State Coroner, having investigated the death of Trent Nathaniel ROBERTSON with an inquest held at Perth Coroners Court, Central Law Courts, Court 85, 501 Hay Street, Perth, on 22 November 2019, find that the identity of the deceased person was Trent Nathaniel ROBERTSON and that death occurred on 27 May 2018 at Royal Perth Hospital, from head and neck injury, with terminal palliative care in the following circumstances: Table of Contents
SUPPRESSION ORDER No reporting/publication of any evidence which relates to the details contained in the Police Emergency Driving Policy.
Trent Nathaniel Robertson (Mr Robertson) died on 27 May 2018 at Royal Perth Hospital from head and neck injuries that he sustained upon crashing his motorcycle after failing to negotiate the roundabout at the intersection of Old Coast Road and Paris Road in Australind, while he was in the course of attempting to avoid a traffic stop by police. He was 44 years of age.
Mr Robertson’s death was a reportable death within the meaning of s 3 of the Coroners Act 1996 (the Coroners Act) because it resulted from injury, and also because it followed the attempted traffic stop by police. The death was reported to the coroner as required by the Coroners Act. By reason of s 19(1) of the Coroners Act I have jurisdiction to investigate the death.
Under s 22(1)(b) of the Coroners Act an inquest into Mr Robertson’s death was mandated because it appeared that the death was caused, or contributed to, by an action of a member of the Police Force (the police).
A death may have that appearance where there is a temporal nexus between an action of a member of the Police Force in connection with the deceased person, and the events leading to death.
Section 22(1)(b) is enlivened when the issue of causation or contribution in relation to a death arises as a question of fact, irrespective of whether there is fault or error on the part of the police.
My primary function is to investigate the death. It is a fact-finding function. Under s 25(1)(b) and (c) of the Coroners Act, I must find, if possible, how death occurred and the cause of death.
Under s 25(2) of the Coroners Act, in this finding I may comment on any matter connected with the death including public health, safety or the administration of justice. This is the ancillary function.
Section 25(5) of the Coroners Act prohibits me from framing a finding or comment in such a way as to appear to determine any question of civil liability or to suggest that any person is guilty of an offence. It is not my
[2020] WACOR 39 role to assess the evidence for civil or criminal liability, and I am not bound by the rules of evidence.
In making my findings I have applied the standard of proof as set out in Briginshaw v Briginshaw (1938) 60 CLR 336 per Dixon J at 361 - 362 which requires a consideration of the nature and gravity of the conduct when deciding whether a matter has been proved on the balance of probabilities.
I held an inquest into Mr Robertson’s death on 22 November 2019. I heard from five witnesses, and I received two Exhibits into evidence, with Exhibit 1 containing 23 tabs.
On 20 December 2019 I received written submissions from the State Solicitor’s Office on behalf of the Western Australia Police Force, directed towards potential recommendations, and making reference to relevant updates to the Emergency Driving Policy and Guidelines of the Western Australia Police Force.
Mr Robertson was born in Hamilton, New Zealand on 1 May 1974. At the time of his death he was living with friends in Western Australia. For approximately four years he had been working in the mining industry, on a Fly-In-Fly-Out basis, but shortly before his death he appears to have lost this job.1
Mr Robertson had one son, who had been living with Mr Robertson’s mother in New Zealand since December 2017. In Australia, he was separated from his wife, who lived with her daughter (his stepdaughter).
This separation was unfortunately acrimonious.2
2 Ibid.
[2020] WACOR 39 sister. His father had died suddenly in August 2015, and this death impacted adversely upon him.3
On Wednesday 16 May 2018, Senior Constable Nicolao and Senior Constable Green were on duty conducting patrols in a Class 1 marked police vehicle (call sign AR204) in the Australind area. Senior Constable Nicolao was driving and Senior Constable Green was the passenger. At approximately 8.19 pm they were travelling in a northerly direction on Old Coast Road.5
As the police approached the intersection with Travers Drive, both Senior Constable Nicolao and Senior Constable Green observed a single headlight approaching in the southbound lane. There were no other vehicles in the area at that time. As the headlight approached, Senior Constable Nicolao noticed that it was a motorcycle, and that it appeared to be speeding.6
It is now known that the motorcycle was a Suzuki GSXR1000 being ridden by Mr Robertson. At the time of these events, the police did not know the identity of the rider.7
Senior Constable Nicolao activated the police vehicle’s mobile radar which registered the motorcycle’s speed as 92 kilometres per hour. In that section of Old Coast Road, the designated speed limit was 60 kilometres per hour. Police called upon Mr Robertson to stop, by activating lights 3 Ibid.
4 Ibid.
5 Exhibit 1, tabs 9 and 10.
6 Ibid.
7 Ibid.
[2020] WACOR 39 and sirens, and executed a U Turn to follow the motorcycle. The police’s intention was to conduct a traffic stop. Mr Robertson accelerated away.8
They therefore deactivated lights and sirens and terminated the attempted traffic stop. Police continued driving South along Old Coast Road, but not at speed.9
Mr Robertson continued riding the motorcycle in a southerly direction along Old Coast Road, at speed. As Mr Robertson entered the intersection with Paris Road he struck the raised kerb of the roundabout, lost control of the motorcycle and was thrown from the machine, impacting heavily with the road.10
Police and first responders went to the assistance of Mr Robertson. He was conveyed to Bunbury Hospital, then transferred to Royal Perth Hospital with serious head injuries. Tragically despite all medical efforts, Mr Robertson was not able to be revived, and he died of his injuries on 27 May 2018.
The details of the attempted traffic stop, also referred to as the attempted Vehicle Interception, appear below.
9 Ibid.
10 Ibid.
11 Exhibit 1, tab 17.
When police are engaging in a Vehicle Interception, they are required to assess the risk to safety of other road users (including the vehicle being intercepted), and of the vehicle under their own control.12
In the event that it becomes apparent the vehicle will not comply with the police’s instruction to stop, and police continue to pursue the vehicle, the matter becomes an Evade Police Intercept Driving Incident. The police’s instruction to stop is made through a number of means, and includes the activation of lights and/or sirens, to signal to the driver that s/he is required to stop for police.13
Once a matter becomes an Evade Police Intercept Driving Incident, the Policy specifies other conditions, one of which is the duty to inform the Police Operations Centre, and to make a situation report available to the Police Operations Centre Communications Controller (both of which are normally communicated by the passenger in the Class 1 police vehicle, and over the police radio).14
At the inquest, I considered the question of whether Senior Constable Nicolao and Senior Constable Green were engaged in a Vehicle Interception Incident, or whether it had progressed to an Evade Police Intercept Driving Incident. For the reasons outlined in this finding, I concluded that it remained an attempted Vehicle Interception Incident.
Senior Constable Nicolao was qualified as a Priority Pursuit Driver, and therefore qualified to undertake both of the above forms of emergency driving. Senior Constable Green was the passenger, and he had similar qualifications.15
When Senior Constable Nicolao and Senior Constable Green first ascertained, through the vehicle’s mobile radar that Mr Robertson’s motorcycle had reached the speed of 92 kilometres per hour on Old Coast 12 Ibid.
13 Ibid.
14 Ibid.
15 Exhibit 1, tab 17; ts 26; ts 30.
[2020] WACOR 39 Road, they determined to conduct a traffic stop, referred to in the Policy as a Vehicle Interception.16
Old Coast Road is a sealed dual carriageway, with a single lane for north bound traffic and a single lane for south bound traffic. Opposing traffic is separated by a concrete median strip. The designated speed limit on that part of the road was 60 kilometres per hour. Senior Constable Nicolao recalled that at that stage the speed of the police vehicle was 55 kilometres per hour. It was dark (being approximately 8.19 pm) and the street lighting was on. The road was dry and visibility was good. That section of the road was straight, and it was free of imperfections or contaminants.17
When police first saw the motorcycle’s headlight coming towards them on Old Coast Road, they were by various estimates between approximately 50 to 80 metres south of the intersection with Travers Drive, and they were facing to the north.18
Senior Constable Nicolao decided to call on Mr Robertson to stop, because he was speeding on the motorcycle. Having decided to conduct what the Policy refers to as a Vehicle Interception, Senior Constable Nicolao pulled over to the left verge of the northbound carriageway and Senior Constable Green activated the vehicle’s emergency lights and sirens, in order to signal to Mr Robertson that he was to stop. However, Mr Robertson travelled past the police on the motorcycle.19
As a consequence, Senior Constable Nicolao executed a U Turn and began to follow Mr Robertson in a southerly direction along Old Coast Road, with lights and sirens activated. It appeared to Senior Constable Nicolao that Mr Robertson was accelerating away on the motorcycle and he began to accelerate fairly heavily after the motorcycle. Senior Constable Green estimated that at this point, just after police turned around, the motorcycle was 400 to 500 metres away from them.20 16 Exhibit 1, tabs 9, 10, 13 and 14; ts 21 to 22; ts 30.
17 Exhibit 1, tabs 9, 10, 13 and 14; Exhibit 2; ts 21 to 24; ts 30 to 34.
18 Ibid.
19 Ibid.
20 Ibid.
In response to questioning about whether Mr Robertson would have been aware of the presence of the police, Senior Constable Nicolao testified that Mr Robertson could not have missed them, due to the brightness of the police lights at night time. Similarly Senior Constable Green testified that he had no doubt that Mr Robertson saw the lights and heard the sirens, and he drew attention to the brightness of the LED lights.21
There were no other vehicles on the road, and I am satisfied that as Mr Robertson rode towards the police, he apprehended that police had activated their lights, and it is likely he also heard the sirens, and that he knew they meant for him to stop.
After travelling a short distance of 100 to 150 metres in a southerly direction along Old Coast Road, Senior Constable Green, with Senior Constable Nicolao’s agreement, deactivated the emergency lights and sirens. Both police officers appear to have reached the decision to cease the Vehicle Interception at the same time.22
At the inquest, Senior Constable Nicolao explained that he decided not to pursue the motorcycle because after he had driven 100 to 150 metres, he formed the view that Mr Robertson was not going to stop. Senior Constable Green reached the same conclusion. Senior Constable Nicolao stopped accelerating when Senior Constable Green deactivated the lights and sirens.23
In reaching his decision to terminate the Vehicle Interception, Senior Constable Nicolao took account of the fact that they did not at that time have Police Air Wing availability in that area, and that he was not aware of other police being available further south. He therefore formed the opinion that in these circumstances the matter was not going to be resolved by stopping Mr Robertson. Senior Constable Green had formed the view that Mr Robertson was exhibiting all the hallmarks of a very dangerous driver who had no regard for his safety. Even before the police executed 21 Ibid.
22 ts 24 to 25.
23 Ibid.
[2020] WACOR 39 to U Turn, Senior Constable Green heard the motorcycle’s engine making a distinctive accelerating sound. Account was taken of the fact that Mr Robertson was on a motorcycle, as part of their overall risk assessment.24
Senior Constable Nicolao testified that he did not get close to the motorcycle after he executed the U Turn, and Senior Constable Green estimated that by the time the police vehicle slowed down, the motorcycle was hundreds of metres away and he could only just see its tail light.25
The evidence of this sequence of events given by the police officers is consistent with the evidence of an eye witness who was driving her vehicle in a northerly direction along Old Coast Road. She was able to observe the sequence from when she had just passed the intersection with Mardo Avenue, save that she recalled the police lights being activated until they arrived at the scene. She did not recall the lights being deactivated.26
I am satisfied that the attempted Vehicle Interception by police ended when police deactivated their sirens, at the same time they likely deactivated their lights (although they might have reactivated them after they apprehended that there had been a crash), and Senior Constable Nicolao decelerated. Regrettably, Mr Robertson continued to accelerate away from police.27
It follows that I am therefore satisfied that the matter did not proceed to an Evade Police Intercept Driving Incident (that is, it did not become a police pursuit), because police ceased following Mr Robertson once they ascertained that he was not likely to comply with the attempted Vehicle Interception (that is, he was not going to stop for them).
25 ts 30.
26 Exhibit 1, tab 19; ts 14 to 17.
27 ts 25.
[2020] WACOR 39 any other vehicles on the road in front of them. Old Coast Road is straight until it intersects with Paris Road at a raised grass roundabout, where it passes straight through and continues.28
As Mr Robertson reached the roundabout at the intersection with Paris Road, the police officers saw the tail light of the motorcycle jump and they inferred, correctly as it transpired, that the motorcycle had crashed.29
Senior Constable Nicolao continued driving towards Mr Robertson, and as he reached the roundabout at the intersection with Paris Road, he saw dust in the air on the southern side of the roundabout. Senior Constable Nicolao drove through the roundabout, and saw debris strewn along the roadway. On the southern verge of Old Coast Road near a driveway, at a distance of approximately 160 metres from the raised grass roundabout, Senior Constable Nicolao saw Mr Robertson laying on his right side.30
The subsequent Major Crash Investigation was able to establish that as Mr Robertson entered the Paris Road intersection, the motorcycle struck the raised kerb of a concrete traffic island at the entrance to the roundabout and then travelled over the top of the roundabout’s grassed surface.
Disturbance to the turfed area was observed, and at this stage it appears Mr Robertson still had some control of the motorcycle.31
At this point, Mr Robertson was thrown from the machine, impacting heavily with the road.32
29 Ibid.
30 Ibid.
31 Ibid.
32 Ibid.
[2020] WACOR 39 provided the court with an estimate to the effect that Mr Robertson was travelling at a speed in excess of 100 kilometres per hour during this phase of the riding.33
The Major Crash Investigation’s estimate of the motorcycle’s speed as it entered the roundabout is consistent with that given by an eye witness who was filling his vehicle with fuel at the BP Petrol Station near the intersection. He observed the motorcycle going past the BP Petrol Station at excessive speed, just before it crashed. By combination of noise emitted from the speed of the revolution of the engine (the revving), and the observed speed of the motorcycle, this eye witness considered it was travelling in excess of 100 kilometres per hour. Within the 30 to 60 seconds of the crash occurring, he was on the scene to offer assistance, and it was at this stage that he saw police.34
The other eye witness who was driving her vehicle in a northerly direction (whose evidence is referred to previously) saw the sequence of events that led to the motorcycle crash and she observed Mr Robertson losing control of the motorcycle at the roundabout. Her conservative estimate of the motorcycle’s speed, also taking into account the revving sounds, was about 100 kilometres per hour.35
She estimated that police were approximately 350 to 400 metres behind the motorcycle when she first saw them heading in the southerly direction.
She also estimated that police were approximately 200 metres behind the motorcycle when she saw the motorcycle crash. She did not consider the police vehicle to be close to the motorcycle at any stage of her observations.36
34 Exhibit 1, tab 18; ts 8 to 12.
35 Exhibit 1, tab 19.
36 Exhibit 1, tab 19; ts 16.
[2020] WACOR 39 evidence to the effect that police arrived within approximately 30 seconds of the crash is consistent with this.37
The evidence establishes that the police vehicle was not travelling at excessive speed, and certainly not at the speed of the motorcycle. A report was produced from the Automated Resource Locator System device in the police vehicle. It is not an authorised speed measuring device, but it does assist me in assessing the evidence regarding the estimated location and speed of the police vehicle. Data is ordinarily sent by such devices at five minute intervals. The data reflects that the maximum speed reached by the police vehicle was 57 kilometres per hour at 8.18 pm (during an earlier stage), and that it was 43 kilometres per hour at 8.26 pm. This is not inconsistent with the tenor of the evidence regarding the speed of the police vehicle.38
Subsequent vehicle examinations showed: a) No damage to the police vehicle, therefore it can be inferred there was no contact between the police vehicle and the motorcycle, consistent with the evidence given to the effect that they were not close together;39 b) The motorcycle had impact predominantly to the front and all over body damage. The automotive mechanic attached to the vehicle inspection unit at the police’s State Operations Centre recorded that the front tyre tread was below the legal minimum required of 1.5 millimetres. A tyre in such a condition may have less grip on a surface under certain circumstances.40
By reason of the evidence of Senior Constable Nicolao and Senior Constable Green, and the eye witnesses, I am satisfied that police were not close to the motorcycle, or in pursuit of the motorcycle, when it crashed.
37 Exhibit 1, tab 9.
38 Exhibit 1, tabs 9 and 16.
39 Exhibit 1, tab 9.
40 Exhibit 1, tab 21.
Both eye witnesses, whose evidence is referred to in this finding, promptly attended upon Mr Robertson to offer first aid. For this purpose, bystanders removed Mr Robertson’s motorcycle helmet. Police arrived after approximately 30 seconds and together they continued to assist until paramedics arrived to take over the resuscitation.42
Records reflect that police contacted the Operations Centre to advise of the crash and request an ambulance at 8.26 pm on 16 May 2018, and that the St John Ambulance Service received a call at 8.28 pm. Paramedics departed promptly at 8.29 pm and arrived at the scene at 8.30 pm. A second ambulance arrived at the scene at 8.51 pm.43
Mr Robertson was unconscious, with a Glasgow Coma Scale of 3/15. The frontal part of his skull was depressed and it was suspected he had a traumatic brain injury. A spinal collar could not be applied as Mr Robertson’s airway was compromised. A decision was made not to intubate him at the roadside and he was taken to Bunbury Hospital. He arrived at Bunbury Hospital at 9.32 pm and he was intubated and stabilised and then transferred by helicopter to Royal Perth Hospital at 10.42 pm on 16 May 2018.44
Mr Robertson was admitted to the Royal Perth Hospital Intensive Care Unit. His medical treatment over the next 10 days involved numerous specialised teams of doctors. Mr Robertson was found to have sustained a severe head injury, with fractures of the skull, bleeding around the brain and brain injury, together with fractures of the spine. His condition was complicated by a stroke, due to injury to one of the main arteries of the neck.45 41 Exhibit 1, tab 9.
42 Exhibit 1, tabs 13, 14, 18, 19 and 23.
43 Exhibit 1, tabs 15 and 23.
44 Exhibit 1, tab 45 Exhibit 1, tab 5.
Dr Cooke reviewed the Royal Perth Hospital records that indicated severe injuries to the head and neck (complicated by a stroke), and a lesser chest injury.47
On 30 May 2018 Dr Cooke formed the opinion that the cause of death was head and neck injuries with terminal palliative care.48
The results of toxicological analysis became available on 9 July 2018, and showed the presence of medications consistent with terminal medical care.
Alcohol and cannabis was not detected. The forensic pathologist’s opinion on the cause of death remained unchanged.49
I accept and adopt Dr Cooke’s opinion. I find that the cause of Mr Robertson’s death was head and neck injuries, with terminal palliative care.
At the time of Mr Robertson’s death he was facing serious criminal charges. He was on bail from a Magistrates Court and due to appear in that court in June 2018. His driver’s licence was subject to a fine suspension (meaning he should not have been riding the motorcycle) and his motorcycle registration was expired by one month. The subsequent 46 Exhibit 1, tabs 2 and 5.
47 Exhibit 1, tab 4.
48 Ibid.
49 Exhibit 1, tabs 4 and 6.
[2020] WACOR 39 investigation revealed that the motorcycle’s number plate had been obscured by a black sock, and I infer that Mr Robertson had done that, or he was aware of it.50
The Internal Affairs Unit investigated the incident and concluded that police did not breach the Policy. I am relevantly informed, but not bound by, the outcome of the Internal Affairs Unit investigation.51
As I foreshadowed at the inquest, having regard to all of the evidence before me, I am satisfied that police were exercising their legitimate policing functions when they attempted the Vehicle Interception of the motorcycle in accordance with the Policy, having ascertained that Mr Robertson was travelling at 92 kilometres per hour in a 60 kilometre per hour zone. I am also satisfied that police ceased their Vehicle Interception appropriately, after assessing the matter in accordance with the Policy.52
Mr Robertson was aware that police wanted him to stop for them, and regrettably he chose to accelerate away from them on his motorcycle, reaching the highly dangerous speed of approximately 100 kilometres per hour. It is unclear, and probably unlikely, that he became aware of the police having ceased their attempted Vehicle Interception. He is likely to have remained focussed on the road before him, but no amount of focus would have saved him from crashing when riding in that manner.
The attempted Vehicle Intercept lasted a matter of seconds. I am satisfied that police did not cause or contribute to Mr Robertson’s death.
51 Exhibit 1, tab 9; ts 36 to 40.
52 Exhibit 1, tabs 10, 13, 14 and 22; ts 42.
[2020] WACOR 39 number plate had been obscured. He knew police had called on him to stop (by activating lights and sirens) and regrettably he chose to accelerate away from them.
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