chambers of state coroner terry ryan · mechanism of fatal injury^ frequency percentage head trauma...

CHAMBERS OF State Coroner Terry Ryan

Office of the State Coroner

Brisbane Magistrates Court

363 George Street

Brisbane QLD 4000

G.PO Box 1649

Brisbane QLD 4001

PH (07) 3898 0360

FX (07) 323 90176

www.courts.qld.gov.au

2 November 2016 Mr Peter Russo MP Chair Finance and Administration Committee Parliament House George Street BRISBANE QLD 4000 email: [email protected] Dear Mr Russo Inquiry into how to improve health and safety outcomes for combat sports contestants in high risk and amateur contests in Queensland Thank you for your letter dated 31 August 2016 regarding the inquiry into health and safety outcomes for combat sports contestants in Queensland. I have obtained data from the National Coronial Information Service in relation to deaths reported to Australian State or Territory Coroners between 01/07/2000 and 31/08/2016, where the deceased has died while engaged in a combat sport-related activity. A copy of NCIS Report CR 16-46 is attached. There were two combat sports related fatalities in Queensland due to external causes in the relevant period. The deaths involved young men who had competed in boxing matches in Mackay in 2010 and in Toowoomba in 2015. There were a further five deaths in Queensland identified as fatalities due to natural causes such as coronary atherosclerosis. No recommendations were made by Queensland coroners in relation to these deaths as inquests were not held as part of the investigation of the deaths. Under section 46 of the Coroners Act 2003 a coroner can only make comments relating to public health and safety and ways to prevent similar deaths following an inquest. However, recommendations made by other State and Territory Coroners are referred to the in the NICS Report.

I have also attached for your information data from the NCIS (CR16-37) in relation to deaths reported to Australian State or Territory Coroners between 01/07/2000 and 31/08/2016, where the deceased has died while engaged in a contact sport-related activity. This data was requested by a Queensland Coroner investigating another contact sport related death that was not a combat sport. This data indicates that 13.4% of the 299 deaths reported across Australia were due to external causes. I trust that this information is of assistance to the Committee. Yours sincerely

Terry Ryan State Coroner

EMAIL: [email protected] WEBSITE: www.ncis.org.au

Coronial Report: CR16-46

NATIONAL CORONIAL INFORMATION SYSTEM

Deaths from Professional and Amateur Combat Sports

in Australia,

2000 – 2016


CR16-46: Deaths from Professional and Amateur Combat Sports in Australia, 2000 – 2016

PURPOSE The purpose of this report is to provide information about deaths reported to an Australian State or

Territory Coroner between 01/07/2000 and 31/08/2016, where the deceased has died while

engaged in a combat sport-related activity.

Both closed and open cases on the NCIS are included.

INTENDED USE OF DATA The data in this report is provided by the NCIS for the purpose requested by Leanne Field, of the

Coroner's Court of Queensland, on behalf of the State Coroner. The data contained here was

requested for use in relation to a response to the Finance and Administration Committee Inquiry

into how to improve health and safety outcomes for combat sports contestants in high risk

professional and amateur contests in Queensland.

As a result, the data may be published in the public domain.

NCIS DISCLAIMER This dataset does not claim to be representative of all relevant cases within the time period

specified. This may be due to; cases still under coronial investigation, missing data, occasional

processing and coding errors. The Department of Justice & Regulation accepts no liability for any

loss or damage that may arise from any use of or reliance on the data.



METHOD

Case Identification

The Query Design Search Screen was used to identify cases of relevance. The method of case

identification involved searching for cases where:

Date notified = Between 01/07/2000 and 31/08/2016

Please note: All time ranges in this report refer to calendar years unless otherwise indicated.

Case status = Open and Closed

Jurisdiction = All Australian States and Territories

Activity Level 1 = Sport and Exercise During Leisure Time

The search was conducted on 31/08/2016.

Data Collection & Analysis

An extract of the NCIS database was performed, containing all cases in Australia where the activity

code was “Sport and Exercise During Leisure Time”. A manual review of the coding of all cases in the

dataset was undertaken in order to confirm that the cases were of relevance. Duplicates were

identified and subsequently removed.

A manual review of the sports coding was undertaken to determine contact sports status. Manual

review was also undertaken of attached documents (police narrative, autopsy report and coronial

findings) for codes such as ‘school sports’ to ascertain whether they were playing a combat sport at

the time.

Cases were removed where the stated sport at the time of the fatal incident was not a combat sport.

Cases summaries were produced from the attached documentation (police narrative, coronial

findings, autopsy report and toxicology results).

This report uses data from the previous NCIS report entitled “CR16-37 Contact Sport-Related

Fatalities Australia, 2006 – 2016”, by Nikki McLean and Thomas Burgess.



LIMITATIONS OF DATA SOURCE Coded fields are not completed until the closure of a case and the extent of information contained in

the attached text reports may vary. There are several other factors which may have influenced the

number of cases identified within this dataset, these are outlined below. Given these factors, there

is a possibility of under-reporting.

Availability of documentation within NCIS database

The level of attachment of documentation varies within the NCIS database according to the

reporting jurisdiction.

Coronial findings in relation to non-inquest cases may not contain details about the circumstances

surrounding death. While best efforts are made to obtain reports for all cases on the NCIS (where

relevant investigations are conducted), the proportion of report attachment varies across

jurisdictions. This variation has the potential to impact the accurate identification of relevant cases

via keyword searching of documents on the NCIS.

For more information about document attachment, please refer to the NCIS Website

(http://www.ncis.org.au/data-collection-2/operational-statistics/).

Quality Assessment of Closed Cases

The NCIS Unit conducts a quality assessment of the coding associated with cases that have been

closed. While every effort is made to quality review closed cases in a timely manner, there may be a

delay between the case being closed and the completion of the quality review. It cannot be

guaranteed that all cases included in this report have been quality assessed.

Quality Assessment of ICD-10 Coding

ICD-10 codes are provided for open and closed cases by the Australian Bureau of Statistics (ABS).

Since 2007, cases which were open during initial ABS coding are revised in the following year. ABS

coding is not quality assured by the NCIS and therefore the NCIS cannot ensure the accuracy of all

ICD-10 coding.

Please refer to the ABS website for more information on their ICD-10 coding processes:

(http://www.abs.gov.au/ausstats/[email protected]/Latestproducts/3317.0.55.001Main%20Features4200

5?opendocument&tabname=Summary&prodno=3317.0.55.001&issue=2005&num=&view=).

http://www.abs.gov.au/ausstats/[email protected]/Latestproducts/3317.0.55.001Main%20Features42005?opendocument&tabname=Summary&prodno=3317.0.55.001&issue=2005&num=&view=

http://www.abs.gov.au/ausstats/[email protected]/Latestproducts/3317.0.55.001Main%20Features42005?opendocument&tabname=Summary&prodno=3317.0.55.001&issue=2005&num=&view=



RESULTS There were seven (7) External Cause and twenty-two (22) Natural Cause deaths identified with the

date of notification between 01/01/2000 and 31/08/2016 that were reported to an Australian State

or Territory Coroner where the deceased has died while engaged in a combat sport-related activity.

Dashes ( - ) indicate that no deaths occurred. Figures are rounded to one decimal place.

Please note that Tables 1 to 6 relate to External Cause deaths only, and Tables 7 to 12 involve

Natural Cause deaths only.

There was an average of less than one (0.4) External Cause deaths of relevance reported per

calendar year.

Table 1: Combat Sports Related Fatalities by Year of Notification (External Cause Deaths Only)

Year of Notification Frequency Percentage

2000* 1 14.3

2001 - -

2002 - -

2003 - -

2004 - -

2005 - -

2006 - -

2007 - -

2008 - -

2009 1 14.3

2010 1 14.3

2011 2 28.6

2012 - -

2013 1 14.3

2014^ - -

2015^ 1 14.3

2016^ - -

Total 7 100

* – From 01/01/2001 for Queensland.

^ – Potentially an underestimate of the number of cases due to the proportion of open cases

remaining for these years of data.

As of 03/10/2016, 72.5% of all 2014 Australian coronial cases on the NCIS have been closed, 52.8%

Attached with this report is an Excel spread sheet named CR16-46: Combat Sport-Related

Fatalities in Australia, 2000 – 2016.xlsx that lists the cases referenced in this report.



of all 2015 Australian cases have been closed, and 18.5% of all 2016 Australian cases have been

closed. For more detailed information, such as a jurisdictional disaggregation, see

http://www.ncis.org.au/wp-content/uploads/2016/10/Monthly-Case-Closure-Statistics.pdf

Table 2: Combat Sports Related Fatalities by Jurisdiction (External Cause Deaths Only)

Jurisdiction Frequency Percentage

NSW 3 42.9

QLD 2 28.6

WA 1 14.3

VIC 1 14.3

SA - -

NT - -

ACT - -

TAS - -

Total 7 100

Table 3: Combat Sports Related Fatalities by Sex (External Cause Deaths Only)

Sex Frequency Percentage

Male 6 85.7

Female 1 14.3

Total 7 100

Table 4: Combat Sports Related Fatalities by Age Range (External Cause Deaths Only)

Age Range [Years] Frequency Percentage

0 - 10 - -

11 - 20 1 14.3

21 - 30 5 71.4

31 - 40 1 14.3

41 - 50 - -

51 - 60 - -

61 - 70 - -

71 - 80 - -

81 - 90 - -

91 and above - -

Total 7 100




Table 5: Combat Sports Related Fatalities by Mechanism of Fatal Injury (External Cause Deaths Only)

Mechanism of Fatal Injury^ Frequency Percentage

Head Trauma - Struck by Another Person

4 57.1

Head Trauma - Contact with Floor

3 42.9

Total 7 100

^ – Categories for mechanism of fatal injury were constructed based on a review of case information

including cause of death, mechanism of injury and object or substance producing injury fields. In all

instances, the primary contributor to the death dictated categorisation (e.g. a death from

asphyxiation caused by hanging where the deceased also had knife-related injuries would still be

classified as ‘Hanging’).

Table 6: Combat Sports Related Fatalities by Sport (External Cause Deaths Only)

Sport played Frequency Percentage

Boxing 3 42.9

Karate 1 14.3

Kick-Boxing 1 14.3

Wrestling - Freestyle 1 14.3

Unspecified Combative sport 1 14.3

Total 7 100



Table 7: Combat Sports Related Fatalities by Year of Notification (Natural Cause Deaths Only)


2000* 1 4.5

2001 1 4.5

2002 1 4.5

2003 1 4.5

2004 2 9.1

2005 2 9.1

2006 1 4.5

2007 2 9.1

2008 - -

2009 - -

2010 1 4.5

2011 6 27.3

2012 2 9.1

2013 1 4.5

2014^ - -

2015^ - -

2016^ 1 4.5

Total 22 100




Although open cases are included in this report, open cases may have incomplete coding on the NCIS

and are therefore not always identified during case identification.








Table 8: Combat Sports Related Fatalities by Jurisdiction (Natural Cause Deaths Only)


VIC 6 27.3

NSW 5 22.7

QLD 5 22.7

WA 4 18.2

SA 1 4.5

TAS 1 4.5

NT - -

ACT - -

Total 22 100

Table 9: Combat Sports Related Fatalities by Sex (Natural Cause Deaths Only)


Male 22 100.0

Female - -

Total 22 100



Table 10: Combat Sports Related Fatalities by Age Range (Natural Cause Deaths Only)

Age Range [Years] Frequency Percentage

0 - 10 - -

11 - 20 2 9.1

21 - 30 1 4.5

31 - 40 2 9.1

41 - 50 7 31.8

51 - 60 7 31.8

61 - 70 2 9.1

71 - 80 1 4.5

81 - 90 - -

91 and above - -

Total 22 100

Table 11: Combat Sports Related Fatalities by ICD-10 Underlying Cause of Death Category (Natural Cause Deaths Only)

ICD-10 Underlying Category* Frequency Percentage

Circulatory System Diseases 17 77.3

Congenital And Chromosomal Abnormalities

1 4.5

Unknown 4 18.2

Total 22 100

* – The “underlying ICD-10 category” was derived from the underlying ICD-10 code that was assigned by the Australian Bureau of Statistics (ABS) to the case record. Cases where the underlying category is “unknown” refer to cases which have not been provided an ICD-10 by the ABS.

Table 12: Combat Sports Related Fatalities by Sport (Natural Cause Deaths Only)

Sport Frequency Percentage

Karate 8 36.4

Boxing 5 22.7

Tae Kwon Do 3 13.6

Other specified Combative Sport

2 9.1

Kung Fu 1 4.5

Jujitsu 1 4.5

Judo 1 4.5

Unspecified Combative sport 1 4.5

Total 22 100



CASE SUMMARIES AND RECOMMENDATIONS The following case summaries were produced from the findings of the investigating Coroner.

Where Coronial findings contained insufficient detail, or were not electronically attached on the

NCIS, the attached police reports were consulted. Police reports contain information that is

collected at the scene of the injury which caused the fatality, and may contain information that is

subject to change.

Please note cases one to seven involve External Cause fatalities only.

Case One Adult (25-44 year olds) The deceased was an adult male who had competed professionally as a Thai boxer for the ten years prior to his death. The deceased was participating in a Thai boxing match, during which he sustained kicks and punches to the head. Shortly after the match, he became unconscious and, upon being conveyed to hospital, was diagnosed with having sustained a severe head injury, having developed a haemorrhage. Surgery was undertaken, however the deceased’s condition remained poor, and he was subsequently diagnosed with brain death. Life support measures were then withdrawn. Comments and Recommendations: To the Minister of Sport and Recreation and the Australian College of Sports Physicians:

1. I recommend that the College and the Combat Sports Authority consult and develop protocols for pre-match and post-match medical screening of combat sports combatants.



Case Two Young adult (15-24 year olds) The deceased was a young adult male who was a professional boxer visiting Australia to train and compete. On the day of his death, the deceased was sparring with another boxer. Both boxers were wearing appropriate gloves and head protection. During the fight, the deceased received a number of blows to the head. At one stage, one of these blows caused the deceased to lose his footing and he became unsteady. The deceased began to bleed from the nose, however once this was attended to, the fight resumed. Shortly afterward, the deceased collapsed and was transferred to hospital. He underwent surgery but was found to have suffered a catastrophic brain injury, and died six days later. Comments and Recommendations: I make the following recommendation(s):

1. That there be a system of regulation implemented which requires: a. Mandatory application for professional registration of boxers proposing to

participate in professional training or who are participating in sparring at a level directed towards professional contest or with a professional boxer; and

b. Mandatory medical certification as to fitness to compete, including blood testing, before a boxer participates in training or sparring at a level directed towards professional contest or with a professional boxer and that such blood testing be undertaken each 6 months.

c. Mandatory reporting of hospitalisation of any boxer of any status whether professional or amateur, for injuries sustained whilst participating in training, or sparring or competition.

d. That the Boxing and Contact Sports Board implement a level of supervision upon gymnasiums, when the training of boxers is occurring at a level directed towards professional participation to ensure compliance.

2. I direct that a copy of this finding and recommendations be provided to the family of the

deceased; other interested parties; The Honourable [Minister for Sport and Recreation]; the Secretary, Department of Planning and Community Development; The Registrar, Professional Boxing and Combat Sports Board (of the State) for the attention of the Board.



Case Three Young adult (15-24 year olds) The deceased was a young adult male who had commenced boxing training approximately four years prior to his death, and later competed as an amateur boxer. In the months prior to his death, the deceased was involved in two incidents: one involved a king hit that he sustained from a disgruntled acquaintance at a local nightclub, and the other involved a vehicle accident in which his car collided with a tree. Following both of these incidents, there was evidence that the deceased experienced vomiting or being dazed and confused. However, he did not complain of further injuries or symptoms following these incidents. In one subsequent boxing match, the deceased was reportedly pale, nauseous and exhausted, although he appeared not to suffer other ill-effects in subsequent matches. On the day of his death, the deceased competed in an amateur boxing match. He was deemed fit to fight by a doctor prior to the match. In the first round of the match, the deceased sustained a punch to the head. Later on in the match, the deceased’s coach noticed that he appeared unwell, and was blinking his eyes as though attempting to correct his vision. The coach stopped the fight and approached the deceased, upon which the deceased lost consciousness and collapsed. He was transported to hospital and later taken to intensive care. However, his condition deteriorated and he died a week later. Case Four Adult (25-44 year olds) The deceased was an adult female who died in her home. Two years prior to her death, the deceased was believed to have sustained a head injury when she fell heavily on the back of her head during a martial arts training session. She suffered from headaches and nausea and was treated by naturopaths, though she was never referred for neurological assessment. On the day of her death, the deceased was found collapsed on the laundry floor of her home. Attending ambulance officers were unable to find any signs of life. The cause of death was deemed to be consistent with epileptiform seizures.



Case Five Young adult (15-24 year olds) The deceased was a young adult male who competed in a professional boxing match two days prior to his death. The match lasted for ten rounds and the deceased was deemed to have lost the fight. He did not lose consciousness during the fight, and appeared to be in sound condition immediately following the match. Within an hour of the fight’s conclusion, the deceased experienced a transient syncopal episode. Although he initially appeared to recover, he then collapsed. A doctor who was present provided assistance and the deceased was transported to hospital. Following a CT scan, it was revealed that the deceased had suffered a traumatic subdural haemorrhage, and he was transferred to another hospital to undergo surgery. The surgery was performed but the deceased was later confirmed to have suffered brain death. Comments and Recommendations: It is clearly evident that the risk of death or serious injury to the brain is one that is faced by participants in the sport of boxing. There have been regular calls for bans on the sport, particularly by national medical associations around the world including the Australian Medical Association. On 22 November 2015 the Australian Medical Association published a position statement concerning combat sport including boxing, recommending that it be banned from both the Olympic and Commonwealth Games and prohibiting the sport for people under the age of 18. The statement also recommended a number of steps designed to minimise harm to amateur and professional participants. In particular there was a recommendation that no contest be permitted unless it occurs where there are readily available adequate neurosurgical and resuscitative facilities for the emergency treatment of an injured participant. In this case the event was held in a regional town where it was thought necessary to transfer [the deceased] to a tertiary facility in [a city] which had expertise in head injuries. Whether earlier treatment at that level would have made a difference in this case is uncertain but it is also clear that the earlier optimal treatment is provided the more likelihood of there being a better outcome. It is the view of the coroner that there is very significant merit in the position of the Australian Medical Association and that its recommendations should be seriously considered.

As well there have been recent references in the media noting that [the state in which the deceased died] is the only state in Australia where combat sports are completely unregulated. The [State] Minister for Sport has advised in statements published in the media that he will seriously look at regulating combat sports. In recent times there has been particular references and government responses to [an anti-violence campaign]. That of course is in response to gratuitous attacks on unsuspecting victims involving punches to the head. By contrast, boxing and other combat sports involve consensual participation in such activities involving much the same risk. Case Six Adult (25-44 year olds) The deceased was an adult male who was undertaking black belt karate grading at the time of his death. On the morning of his death, the deceased commenced sparring with an opponent, during which time it was noted that he was running out of stamina and had fallen once, hitting his head



heavily on the padded floor. He fell another two times, again striking his head (though less severely than following the first fall). None of these falls were as a consequence of sustaining strikes to the head from his opponent. He was approached by a trainer and confirmed that he felt fine. During further sparring with another opponent later that morning, the deceased fell again, and the grading was ceased. The deceased left the grading hall, and subsequently collapsed, unconscious. The deceased was transported to hospital where he passed away as a result of head injuries. Case Seven Adult (25-44 year olds) The deceased was an adult male who had no known significant medical history. On the day of his death, the deceased was participating in wrestling training at a martial arts gymnasium. During this training, the deceased fell backwards, striking his head on the training mats. He immediately lost consciousness and emergency services were contacted. He was conveyed to hospital, where he was found to have fixed and dilated pupils. A CT scan revealed an acute subdural haematoma. Surgical intervention took place, however the deceased suffered irreversible brain trauma and was placed on life support. He passed away six days later.



Please note that Cases 8 to 29 involve Natural Cause deaths only. Case Eight Young adult (15-24 year olds) The deceased was a young adult male who had a pre-existing heart condition and was participating in a martial arts training session prior to his death. During this session, the deceased was sparring with an opponent for short, intense rounds followed by periods of rest. The deceased’s opponent had the deceased held in a form of choke hold, to which the deceased succumbed and ‘tapped out’. His opponent subsequently released his grip and walked away. The deceased then lay on the ground, apparently exhausted. It was then discovered by trainers that the deceased had become unconscious. Emergency services were contacted and CPR was commenced. It was confirmed that the deceased had entered a state of cardiac arrest and he was transported to hospital. However, continued resuscitation attempts were unsuccessful. Comments and Recommendations:

1. I recommend to the Minister for Fair Trading that, if this has not already been done, he consider liaising with Fitness Australia to develop, implement and reinforce a code of conduct for the fitness industry in NSW that would include the following recommendation.

2. I recommend that Fitness Australia consider including in the National Fitness Industry Code of Practice it is currently developing or, if more appropriate, its guidelines for pre-exercise risk assessment and management, a guideline to the following effect:

If a prospective client is assessed under its pre-exercise screening tool as being at significant risk, the client should be referred to his or her medical practitioner(s) for clearance to undertake the proposed fitness program. The client should not be accepted into the program unless written clearance is received from the client’s doctor to do so.

Case Nine Young adult (15-24 year olds) The deceased was a young adult male who was visiting his uncle at the time of his death. The deceased had no prior significant medical history, although there was a family history of cardiac deaths, and was not taking any prescription medications at the time of his death. Whilst at his uncle’s home, the deceased began boxing training in his uncle’s shed. Using a boxing bag, he completed two rounds of two minutes of boxing followed by one minute of rest. Following this, he went into the house with his uncle and asked for a drink. His uncle then returned to the shed, and, shortly afterward, heard heavy breathing coming from the house. He found the deceased lying face down on the floor. CPR was commenced and the deceased was conveyed to hospital by ambulance. However, he was unable to be revived.



Case Ten Adult (25-44 year olds) The deceased was an adult male who had five years of experience in jujitsu. On the day of his death, the deceased competed in a martial arts grading event. Prior to the event, the deceased warmed up and trained. During the event, the deceased was grappling with an opponent when he asked to stop. The opponent immediately desisted, noticing that the deceased appeared exhausted. The deceased then got up onto his knees before falling face first on the ground, gasping for air. CPR was administered and an ambulance contacted, however the deceased was unable to be revived. His death was later found to have been caused by coronary atherosclerosis. Case Eleven Adult (25-44 year olds) The deceased was an adult male who was undertaking a karate session at the time of his death. The deceased suffered from a kidney disorder and high blood pressure, as well as asthma. The karate session was described as relatively light. At one point, the deceased was noticed to fall to one knee and collapse backwards, struggling for breath. CPR was commenced and emergency services contacted. Upon arrival, the ambulance officers continued CPR, however their attempts to revive the deceased were unsuccessful. Case Twelve Adult (25-44 year olds) The deceased was an adult male who suffered from type 1 diabetes and was participating in a martial arts class at the time of his death. During this class, the deceased began complaining of indigestion and laboured breathing. The deceased then sat down in a chair and subsequently collapsed. CPR was attempted by bystanders and later by ambulance officers. However, the deceased was unable to be revived. Case Thirteen Adult (25-44 year olds) The deceased was an adult male who was undertaking a karate class at the time of his death. During the warm-up for the class, the deceased collapsed. The class instructor attempted CPR until ambulance officers arrived. However, further attempts to revive the deceased were unsuccessful.



Case Fourteen Middle aged (45-64 year olds) The deceased was a middle aged male who had a history of Marfan’s syndrome, aortic root dilatation and schizophrenia. At the time of his death, the deceased was undertaking a karate lesson, during which he complained of dizziness and collapsed. Emergency services were contacted and ambulance personnel attended. Despite attempts to resuscitate the deceased, he was unable to be revived. Case Fifteen Middle aged (45-64 year olds) The deceased was a middle aged male who was participating in a karate class at the time of his death. For several weeks prior to his death, the deceased had been suffering from the flu, from which he was struggling to recover, and for which he took flu tablets. During this class, the deceased undertook a variety of exercises, including push ups, sit ups, kicks and punches. The deceased informed his instructor that he was not feeling well and walked to the rear of the hall. Upon sitting on the edge of kitchen table, the deceased collapsed, falling backwards and striking the side of the oven. Ambulance officers were called to the scene and resuscitation attempts made, however, these were unsuccessful. Case Sixteen Middle aged (45-64 year olds) The deceased was a middle aged male who had a history of hypertension and hypercholesterolaemia. He suffered from an acute myocardial infarction thirty years prior to his death. On the day of his death, the deceased was participating in karate training when he was observed to become disorientated and began convulsing. An ambulance was contacted, however the deceased was unable to be resuscitated. Case Seventeen Middle aged (45-64 year olds) The deceased was a middle aged male who was attending Tae Kwon Do training. During this training, the deceased collapsed and appeared to be having a seizure. Emergency services were contacted, and, upon their arrival, paramedics commenced CPR. The deceased was conveyed to hospital, where resuscitation attempts continued. However, he was unable to be revived.



Case Eighteen Middle aged (45-64 year olds) The deceased was a middle aged male who had a history of ischaemic heart disease and had previously undergone heart stent operations. He was noted to have been feeling ill in the three days prior to his death, though he had not sought medical attention. On the evening of his death, the deceased attended his usual Tae Kwon Do class. During this class, the deceased became short of breath. He then became unconscious, though he regained consciousness a short time later. The deceased was noted to be rambling and was unable to hold a conversation. An ambulance was contacted, and, upon the deceased losing consciousness again, CPR was attempted until ambulance officers arrived. Despite continued attempts to resuscitate him, he was unable to be revived. Case Nineteen Middle aged (45-64 year olds) The deceased was a middle aged male who was participating in a Tae Kwon Do lesson on the afternoon of his death. During this lesson, the deceased suddenly crouched down and collapsed. An ambulance was called and attempts were made to resuscitate the deceased. Upon their arrival, ambulance officers were unable to find a pulse or evidence of breathing, and resuscitation attempts were continued whilst he was conveyed to hospital. However, these attempts were unsuccessful. Case Twenty Middle aged (45-64 year olds) The deceased was a middle aged male who was participating in a martial arts class on the evening of his death. During the class, the deceased’s face became flushed. When the instructor made mention of this, the deceased stated that he always became flushed when exercising. Following the class, the deceased was discovered by a security guard in the gymnasium’s car park, leaning over the steering wheel of his car. An ambulance was contacted and resuscitation was commenced. However, attending ambulance officers were unable to find signs of life. A post mortem examination revealed the presence of coronary vessel disease. Case Twenty-One Adult (25-44 year olds) The deceased was an adult male who was boxing with friends on the day of his death. The deceased had been diagnosed with atrial fibrillation three years prior to his death, for which he took medication. Following completion of the boxing, the deceased appeared to be out of breath. He then climbed onto a trampoline and lay on his back. His friends began CPR and emergency services were contacted. Upon their arrival, paramedics continued efforts to resuscitate the deceased, however these were unsuccessful.



Case Twenty-Two Middle aged (45-64 year olds) The deceased was a middle aged male who was at the home of a friend on the day of his death. Three days prior, the deceased had been motor bike riding when he complained of pains in his chest. Since that time, the deceased had been red in the face and suffering from tiredness. On the day of his death, the deceased was taking part in a boxing fitness session with a group of people. This involved running, the use of punching bags and pads, and light sparring consisting of two minutes of sparring and one minute of rest. The deceased was using an ear plug as it was believed he had damaged his eardrum at a previous boxing session. After completing two minutes of sparring, the deceased complained of chest pain. He then completed a further two rounds of sparring, following which he collapsed to the ground and was unable to be revived. Case Twenty-Three Middle aged (45-64 year olds) The deceased was a middle aged male with no known significant medical history. At the time of his death, the deceased was at a gym. Upon sitting on a bench, the deceased slumped to the floor. Resuscitation was commenced and emergency services contacted. Upon the arrival of ambulance officers, the deceased was transferred to hospital, and despite continued attempts to resuscitate him, he was unable to be revived. Case Twenty-Four Older person (65 year olds and above) The deceased was an older adult male who was teaching judo at the time of his death. Whilst he was teaching, the deceased collapsed and was witnessed to have a generalised tonic/clonic seizure with post ictal conscious state. The deceased was conveyed to hospital where he was intubated and a CT scan revealed an intracerebral haemorrhage. Following this, he was transferred to another hospital, where a temporal lobe intracranial haemorrhage was detected. The deceased’s brain became increasingly unresponsive, and further active management was withdrawn.

Case Twenty-Five Young adult (15-24 year olds) The deceased was a young adult male with a history of a benign cyst in his brain, which was diagnosed following a motor vehicle collision four years prior to his death. Within the two months prior to his death, the deceased had complained of headaches to his doctor, however, following more scans, there was considered to be no change to the cyst in his brain. On the day of his death, the deceased complained of a headache following work. He took painkillers for this and rested on his couch at home before attending karate training. During training, he continued to complain of his headache, although he persisted with his training. Whilst conducting sit-ups, the deceased rolled onto his side and began to vomit. He then began urinating and went into a state of cardiac arrest. CPR was conducted, and although paramedics arrived at the scene, the deceased was unable to be revived.



Case Twenty-Six Middle aged (45-64 year olds) The deceased was a middle aged male who was participating in a martial arts lesson on the day of his death. The routine undertaken by the participants was described as fairly strenuous, though it did not involve body contact. During the lesson, and whilst punching hand pads held by another participant, the deceased suddenly collapsed, striking his head on the floor. CPR was administered and was continued by attending ambulance officers, who also administered adrenaline. However, the deceased was unable to be revived. Case Twenty-Seven Middle aged (45-64 year olds) The deceased was a middle aged male who suffered from diabetes, although he took no medication. He used a ventolin puffer when he became short of breath. He worked as a fitness instructor and participated in weekly caged fitness workouts. On the day of his death, the deceased was participating in a workout when he became breathless, and collapsed shortly afterward, hitting his head. Despite attempts to resuscitate the deceased, he was unable to be revived. Case Twenty-Eight Middle aged (45-64 year olds) The deceased was a middle aged male who had a history of bipolar disorder, for which he took medication. On the day of his death, the deceased returned home from shopping with a friend and requested that the friend participate in some boxing training with him. This involved the friend holding up mitts which the deceased punched for approximately ten minutes. Following this, the deceased collapsed, striking his head on a table. Emergency services were contacted and he was transported to hospital, where he was pronounced deceased. Case Twenty-Nine Middle aged (45-64 year olds) The deceased was a middle aged male who was participating in a martial arts class at the time of his death. During the class, the deceased began to suffer from shortness of breath, and went to get a drink of water. He then sat down, and complained of feeling unwell. An off-duty nurse who was present checked the deceased’s blood pressure, which was noted to be low. An ambulance was contacted, and ambulance attendees ascertained that the deceased was suffering from a blocked artery in his heart. The deceased was conveyed to hospital, whereupon further tests were conducted. He was then transferred to another hospital, where he went into a state of cardiac arrest and was unable to be resuscitated.



DATA SOURCES

Data on the NCIS has been provided by each State and Territory Coroner’s Office around Australia

and New Zealand. Additional codes are provided by the Australian Bureau of Statistics (ABS) and

Safe Work Australia.

ACT Coroner’s Court

MAGISTRATES COURT of

TASMANIA

CORONIAL DIVISION

NOTE: In some States/Territories the Coroner’s Office is part of the Magistrate’s Court.

FUNDING AGENCIES

Operational funding for the NCIS is provided by the following agencies:

Each State and Territory Justice/Attorney-General’s Department

Australian Department of Health

Australian Institute of Criminology

Safe Work Australia

Australian Competition and Consumer Commission

Australian Department of Infrastructure and Regional Development

The New Zealand Ministry of Justice

EMAIL: [email protected] WEBSITE: www.ncis.org.au

Coronial Report: CR16-37


Contact Sport-Related Fatalities in Australia,

2000 – 2016


CR16-37: Contact Sport-Related Fatalities in Australia, 2000 – 2016

PURPOSE The purpose of this report is to provide information about deaths reported to an Australian State or

Territory Coroner between 01/07/2000 and 31/08/2016, where the deceased has died while

engaged in a contact sport-related activity.

Both closed and open cases on the NCIS are included.

INTENDED USE OF DATA The data in this report is provided by the NCIS for the purpose requested by Leanne Field, of the

Coroner's Court of Queensland, on behalf of the Coroner. The data contained here was requested

for use in the inquest into case QLD.2015.2308

As a result, the data was not requested for publication in the public domain.

NCIS DISCLAIMER This dataset does not claim to be representative of all relevant cases within the time period

specified. This may be due to; cases still under coronial investigation, missing data, occasional

processing and coding errors. The Department of Justice & Regulation accepts no liability for any

loss or damage that may arise from any use of or reliance on the data.



METHOD

Case Identification

The Query Design Search Screen was used to identify cases of relevance. The method of case

identification involved searching for cases where:

Date notified = Between 01/07/2000 and 31/08/2016

Please note: All time ranges in this report refer to calendar years unless otherwise indicated.

Case status = Open and Closed

Jurisdiction = All Australian States and Territories

Activity Level 1 = Sport and Exercise During Leisure Time

The search was conducted on 31/08/2016.

Data Collection & Analysis

An extract of the NCIS database was performed, containing all cases in Australia where the activity

code was “Sport and Exercise During Leisure Time”. A manual review of the coding of all cases in the

dataset was undertaken in order to confirm that the cases were of relevance. Duplicates were

identified and subsequently removed.

A manual review of the sports coding was undertaken to determine contact sports status. Manual

review was also undertaken of attached documents (police narrative, autopsy report and coronial

findings) for codes such as ‘school sports’ to ascertain whether they were playing a contact sport at

the time.



LIMITATIONS OF DATA SOURCE Coded fields are not completed until the closure of a case and the extent of information contained in

the attached text reports may vary. There are several other factors which may have influenced the

number of cases identified within this dataset, these are outlined below. Given these factors, there

is a possibility of under-reporting.

Availability of documentation within NCIS database

The level of attachment of documentation varies within the NCIS database according to the

reporting jurisdiction.

Coronial findings in relation to non-inquest cases may not contain details about the circumstances

surrounding death. While best efforts are made to obtain reports for all cases on the NCIS (where

relevant investigations are conducted), the proportion of report attachment varies across

jurisdictions. This variation has the potential to impact the accurate identification of relevant cases

via keyword searching of documents on the NCIS.

For more information about document attachment, please refer to the NCIS Website

(http://www.ncis.org.au/data-collection-2/operational-statistics/).

Quality Assessment of Closed Cases

The NCIS Unit conducts a quality assessment of the coding associated with cases that have been

closed. While every effort is made to quality review closed cases in a timely manner, there may be a

delay between the case being closed and the completion of the quality review. It cannot be

guaranteed that all cases included in this report have been quality assessed.



RESULTS There were two hundred and ninety nine (299) deaths identified with the date of notification

between 01/01/2000 and 31/08/2016 that were reported to an Australian State or Territory Coroner

where the deceased has died while engaged in a contact sport-related activity. Dashes ( - ) indicate

that no deaths occurred. Figures are rounded to one decimal place.

There was an average of eighteen (17.9) deaths of relevance reported per calendar year.

Attached with this report is an Excel spread sheet named CR16-37: Contact Sport-Related

Fatalities in Australia, 2000 – 2016.xlsx that lists the cases referenced in this report.



Table 1: Contact Sports Related Fatalities by Year of Notification


2000* 7 2.3

2001 19 6.4

2002 20 6.7

2003 21 7.0

2004 19 6.4

2005 22 7.4

2006 21 7.0

2007 23 7.7

2008 19 6.4

2009 27 9.1

2010 28 9.4

2011 22 7.4

2012 18 6.0

2013 11 3.7

2014^ 6 2.0

2015^ 12 4.0

2016^ 4 1.3

Total 299 100




Although open cases are included in this report, open cases may have incomplete coding on the NCIS

and are therefore not always identified during case identification.








Table 2: Contact Sports Related Fatalities by Jurisdiction


NSW 111 37.1

VIC 70 23.4

QLD 43 14.4

WA 29 9.7

NT 16 5.4

SA 14 4.7

TAS 12 4.0

ACT 4 1.3

Total 299 100

Table 3: Contact Sports Related Fatalities by Sex


Male 291 97.3

Female 8 2.7

Total 299 100

Table 4: Contact Sports Related Fatalities by Age Range

Age Range (Years) Frequency Percentage

0 - 10 2 0.7

11 - 20 41 13.7

21 - 30 58 19.4

31 - 40 68 22.7

41 - 50 64 21.4

51 - 60 49 16.4

61 - 70 13 4.3

71 - 80 4 1.3

81 - 90 - -

91 and above - -

Total 299 100



Table 5: Contact Sports Related Fatalities by Recommendations

Recommendations/Comments made

Frequency Percentage

Yes 10 3.3

No 289 96.7

Total 299 100

* – The “underlying ICD-10 category” was derived from the underlying ICD-10 code that was assigned by the Australian Bureau of Statistics (ABS) to the case record. Cases where the underlying category is “unknown” refer to cases which have not been provided an ICD-10 by the ABS.

Table 6: Contact Sports Related Fatalities by the ICD-10 Underlying Category

ICD-10 Underlying Category* Frequency Percentage

Circulatory System Diseases 199 76.0

External Causes 35 13.4

Congenital And Chromosomal Abnormalities 11 4.2

Endocrine, Nutritional And Metabolic Diseases 6 2.3

Symptoms And Abnormal Findings NEC 4 1.5

Nervous System Diseases 2 0.8

Blood, Blood Forming Organ And Immune Disorders 1 0.4

Infectious And Parasitic Diseases 1 0.4

Respiratory System Diseases 1 0.4

Digestive System Diseases 1 0.4

Musculoskeletal System Diseases 1 0.4

Unknown 37 12.4

Total 299 100



Table 7: Contact Sports Related Fatalities by Sport played

Sport played Frequency Percentage

Australian Rules Football 71 23.7

Outdoor Soccer 56 18.7

American Touch Or Tag Football 19 6.4

Basketball 37 12.4

Rugby League 26 8.7

Rugby Union 16 5.4

Indoor Soccer 11 3.7

Field Hockey 10 3.3

Karate 9 3.0

Boxing 8 2.7

Team Ball Sport (Unspecified) 8 2.7

Football (Unspecified) 6 2.0

Team Ball Sport (Other Specified Type) 5 1.7

Tae Kwon Do 3 1.0

Combative Sport (Other Specified Type) 2 0.7

Combative Sport (Unspecified) 2 0.7

Rugby (Unspecified) 2 0.7

Football (Other Specified Type) 1 0.3

American Tackle Football 1 0.3

Floor Hockey 1 0.3

Judo 1 0.3

Jujitsu 1 0.3

Kick-Boxing 1 0.3

Kung Fu 1 0.3

Wrestling- Freestyle 1 0.3

Total 299 100



CASE SUMMARIES AND RECOMMENDATIONS

NSW.2001.2620

Child (0-14 year olds)

The deceased was a male child who lived with his father across the road from an electrical sub-

station. After school, the deceased had taken his soccer ball across the road to kick it against the

electrical sub-station compound brick wall. For an unknown reason, the deceased has entered

the compound, has come into contact with an electrical transformer and has been electrocuted.

The electrical sub-station is not a manned station, and it wasn’t until the next morning that

employees from the sub-station conducting repair work found the deceased.

Comments and recommendations

1. That Energy Australia immediately review its design proposals for the Cronulla Electricity

Substation to ensure the perimeter gates and fences cannot be scaled, and implement

any revised proposals by 30 June 2003.

2. Energy Australia immediately review its design proposals for the locking mechanisms on

its doors at the Cronulla Electricity Substation and, in particular, to consider the

installation of electronic access. Any such revised proposal to be implemented by 30 June

2003.

3. Energy Australia adopt the security design proposals implemented at the Cronulla

Electricity Substation at all its substations if practicable.

4. Energy Australia institute a system of monthly security inspections of all its electricity

substations as soon as practicable.

5. Energy Australia prepare a specific checklist form setting out the security features to be

checked at each electricity substation at the time of the monthly security inspections.

6. A copy of this judgment be forwarded to the Council of the Standards Association of

Australia and the Electricity Council of New South Wales.



NSW.2002.6775

Adult (25-44 year olds)

The Indigenous deceased was an inmate of the Grafton Correctional Centre serving a sentence of

eight years and nine months for armed robbery. On the day of his death, the deceased was

playing touch football with other inmates in the compound area of the prison. The deceased and

other inmates were playing for around 90 minutes, and shortly after finishing the game, the

deceased complained of feeling unwell. The deceased was located a short time later in an

unconscious state on the floor of the toilet block and was unable to be revived.

Comments and Recommendations

To the Minister for Corrective Services, To the Minister for Aboriginal Affairs and To the

Minister of Health

1. All Aboriginal inmates, on reception to the Metropolitan Remand and Reception Centre,

are to attend a ‘medical officer clinic’ for review.

2. The ‘reviewing medical officer’ is to advise Corrective Services, in writing, of the results of

the medical review, as soon as practical. Copies of this advising is to be kept on file with

Justice Health and Corrective Services.

3. The Aboriginal Vascular Programme be developed and promoted to ensure all Aboriginal

inmates are aware of this extremely valuable scheme and the importance of screening.

Both Corrective Services and Justice Health files should carry a notation that the

programme has been offered to the inmate and whether they participated or declined.

4. That all inmates attended to after hours by a clinician for any medical alert, be reviewed

by a doctor the following day.



NSW.2010.2522

Young Adult (15-24 year olds)

The deceased was a sixteen year old international student, who was on a scholarship to St

Andrews Cathedral School. The deceased had moved here with his mother from Zimbabwe. On

the day of his death, the deceased attended and played in a rugby game. At approximately eight

minutes into the second half, the deceased was involved in a heavy tackle, where he was hit by a

shoulder in between the between the chest and abdomen. He was transported to hospital. The

deceased was seen by a junior doctor who was not familiar with sporting injuries, and was not

examined adequately by another doctor who discharged the deceased with a script for Panadeine

Forte. The deceased complained of pain throughout the next day and was given the Panadeine

Forte, however the deceased was found deceased on the couch the following day.


To the Minister of NSW Health:

Noting that the Garling Report made a recommendation concerning the supervision of junior

clinicians which appears to be very useful but does not cover the situation for overseas trained

doctors that have more than two years post graduate experience in countries outside of Australia,

I make the following recommendation:

NSW Health should consider developing and implementing state wide policies setting out a best

practice model for the supervision of overseas trained non specialist doctors working in

Australian hospitals for the first time. This policy should:

a) Define supervision;

b) Define the objectives and content of supervision;

c) Define the supervisory relationship including the roles and responsibilities of clinical

supervisors and trainees;

d) Set out mechanisms for resolving difficulties relating to inadequate supervision; and

e) Recognise the importance of the supervisors role.

To the Executive Officer of the Australian Medical Council:

The Australian Medical Council should consider introducing specific topics in the examination

required for the registration of overseas trained doctors which address the following:

a) Communication skills;

b) Handover; and

c) Note taking.

To the Executive Officer of the NSW Medical Board:

The NSW Medical Board should give consideration to the need for better pathways of supervision

for overseas trained non specialist doctors working in NSW hospitals for the first time and that

the NSW Medical Board should liaise with NSW Health in this regard.



NSW.2011.3490


The deceased was a 35 year old male who was in Australia from the United Kingdom on a

tourist/holiday visa. The deceased trained as a Thai kickboxer and has been competing at a

professional level for the last 10 years, and has had 12 professional fights. On the day of his

death, the deceased was participating in a Thai kickboxing match and had been punched and

kicked in the head numerous times throughout the fight. The deceased finished the match and

complained of a sore hip, and had two cuts above his forehead. While waiting for the doctor, the

deceased collapsed and was transported to hospital, but despite a craniotomy to reduce pressure

on his brain, the deceased passed away.


To the Minister of Sport and Recreation and the Australian College of Sports Physicians:

I recommend that the College and the combat Sports Authority consult and develop protocols for

pre-match and post-match medical screening of combat sports combatants.



NSW.2013.709

Young adult (15-24 year olds)

The deceased was a twenty year old male who was concerned about his weight, and joined a

martial arts gym for fitness, despite knowing he had a pre-existing genetic heart condition which

results in a hardening of the heart muscle. This condition is known to cause sudden and

unexpected cardiac arrests in young people, especially under the stress of hard exercise. On the

day of his death, the deceased participated in a Jujitsu class where he was sparring with another

person, who restrained the deceased in a form of choke hold on the ground. The deceased

‘taped out’ and the other person released his grip on the deceased and walked away. However

the deceased did not move and despite resuscitation efforts, was unable to be revived.


I recommend to the Minister for Fair Trading that, if this has not already been done, he consider

liaising with Fitness Australia to develop, implement and reinforce a code of conduct for the

fitness industry in NSW that would include the following recommendation:

I recommend that Fitness Australia consider including in the National Fitness Industry Code of

Practice it is currently developing or, if more appropriate, its guidelines for pre-exercise risk

assessment and management, a guideline to the following effect:

If a prospective client is assessed under its pre-exercise screening tool as being at significant risk,

the client should be referred to his or her medical practitioner (s) for clearance to undertake the

proposed fitness program. The client should not be accepted into the program unless written

clearance is received from the client’s doctor to do so.



NT.2012.39


The deceased is a 24 year old Indigenous man who played in a local Australian Rules football team

on weekends, was playing football in a competitive game that commenced at 4.30pm due to the

heat at that time of year. The maximum temperature reached that day was 38 degrees. The

deceased played for half a game, and then complained of being dizzy and feeling pain. He was

taken to a medical clinic and the nurse on call was unable to obtain the deceased’s blood

pressure. He then treated the deceased for dehydration, giving the deceased saline solution. The

nurse did not contact it attempt to contact the District Medical Officer or Rostered Rural Medical

Practitioner. However, the deceased then became unresponsive and was unable to be revived,

with the cause of death being a coronary arthrosclerosis, and a completely blocked artery.


[I recommend that] consideration be given by those charged with editing the CARPA

manual to it being amended so that there is a specific sub-chapter, preferably in the

Emergency section, that deals with the problem of the diagnosis of heart attack victims

who are not displaying chest pains. This is for the specific purpose of assisting medical

personnel placed in this position of making the correct provisional differential diagnosis.

This should also address how a provisional diagnosis of cardiac disease may be confused

with a diagnosis of dehydration.

That consideration be given by those charged with editing the CARPA manual to it being

amended so that there is a specific chapter that deals with dehydration that is both in a

separate chapter and which deals specifically with adults.

That consideration be given by those charged with editing the CARPA manual to it being

amended so that there is a specific chapter in the Emergency section specifying that, in

an emergency presentation, an ECG test should be conducted I all cases in which blood

pressure is unable to be obtained or hypotension (low blood pressure) exists. In addition,

that consideration ought to be given for the manual to be amended so as to require, that

in the circumstance of a nurse being placed in the position of having to make a

provisional diagnosis in circumstances such as the deceased’s case, that the nurse be

required to phone the DMO for medical assistance.

I acknowledge fully the efforts of the Department of Health to promote its chronic

disease strategy comprising Adult Health Checks and Cardiovascular Risk Assessments. I

recommend that by way of supplementing these efforts, that substantial further

education be encouraged, both of medical personnel and of Aboriginal people, especially

in remote areas, of the reality of young Aboriginal people developing cardiac disease at a

very early age. This point must be driven home to all medical personnel in the NT to

assist them in making the correct diagnosis of cardiac disease, particular in the

circumstances as they presented in the case of the deceased. It must also be emphasised

to all medical personnel and Aboriginal people in the NT, that heart attacks can occur in

the absence of chest pains.



Having previously acknowledged the efforts of the Department of Health, I recommend

that a coordinated strategy be embarked upon by the Department of Health for the

purpose of screening of heart disease in young Aboriginal people, especially in remote

areas of the NT. I recommend that a proactive approach be taken in this regard and that

it extends to the NGO sector, and in particular, organisations such as Sunrise Health.

I recommend that the Department of Health engage in a coordinated strategy to educate

medical practitioners and nurses in this field to engage in proactive testing and screening

for cardiac disease.

I recommend that Sunrise Health Service conduct a review of its own practices and staff

with particular efforts being made to encourage training of staff to be proactive in

screening for cardiac disease, and conducting the appropriate tests and treatment plans

pursuant to the protocol specified in the CARPA manual. I encourage Sunrise Health

Service to liaise with the Department of Health in this regard and also in regard to the

education of Sunrise’s clientele especially in regard to the education of Sunrise’s clientele

especially in regard to cardiac risk identification and avoidance. I emphasise that Sunrise

advertise the point in its clinics that unless dealt with, heart disease will kill, and will

strike down many young people unless steps are taken to deal with it. I would further

emphasise that Sunrise promote the point that I have emphasised in these findings that

Coronary Heart disease can strike without warning and without chest pains. Specifically,

the importance of regular wellness checks must be emphasised by Sunrise and impressed

upon its clientele.

The risk of smoking cigarettes and the very high rate of smoking amongst Aboriginal

communities in the NT must be part of a public health campaign targeted at Aboriginal

people that emphasises the grave danger to the health of all smokers and the significant

risk of early death. Such a public education campaign could include a reference to the

fact that the smoking of a small quantity of cigarettes prior to a football match, as

occurred in this case, possibly can produce a spam in an artery and contribute directly to

causing a heart attack, leading directly to death.

Regarding the installation of ISTAT devices, I understand that they have been distributed

to major health clinics as well as centres with populations in excess of 1,000 or so

throughout the NT, I recommend, given their effectiveness, that they be installed in all

medical clinics in the NT, The ability to have a quick and reliable analysis of blood cannot

be underestimated. Together with an up to date ECG device, it means that much more

expensive technology is not necessary in order to promptly ascertain a diagnosis of a

cardiac issue of a patient living in a remote area.

If an ISTAT device is not available at a clinic, that clinic must ensure that it has a Troponin

test kit that is available and functioning for the purpose of testing for this important

enzyme.

I endorse the installation of the most up to date ECG devices (that are able to transmit

results digitally to an on call cardiologist for immediate review) to all medical facilities in

the NT. I understand from [a medical practitioner] that these devices are being delivered



throughout the entire NT at this point and that it is expected that this will be completed

in the next month or so. This is to be commended.

I recommend that the education of nurses emphasise that a nurse not make a provisional

diagnosis of a medical problem unless there is clear support for it in the CARPA manual.

Further, in terms of making a provisional diagnosis, if in any doubt, a medical practitioner

must be consulted immediately. Finally, in terms of making a provisional diagnosis it

ought to be emphasised that a nurse (or doctor) must consult the patient history and

furthermore, make a note of what was discovered in that regard in the clinical or patient

notes.

I recommend that the Central Australian Rural Practitioners Association consider the

findings of this Inquest when preparing the next edition of the CARPA manual.



NT.2012.68


The deceased was a twenty eight year old Indigenous person who played Australian Rules football

in the community with his friends. On the day that the deceased died, he had played a

competitive game and at the conclusion of the game, immediately complained of shortness of

breath. The deceased went home after smoking a few cigarettes however was still experiencing

shortness of breath, and a concerned relative obtained medical assistance from a clinic across the

road. The deceased then felt better after observations were made, and walked home but

deteriorated 45 minutes later and was unable to be revived. The cause of death was due to a

blockage in the artery.


Again, in relation to the early detection of coronary artery disease in young aboriginal people, I

have dealt with this in detail in my Findings and Recommendations in respect to the associated

inquest that concerned [the deceased] (as above). I adopt those recommendations for the

purpose of this inquest.

VIC.2002.926

Child (0-14 year olds)

The deceased was a nine year old child who had been playing basketball with a friend at the rear

of his home. The basketball backboard had been attached by the deceased’s father to a brick

parapet above garage and a piece of pine timber using two bolts. The children of the family had

put two mattresses underneath the ring as a springboard to dunk the ball through the hoop. The

deceased has walked towards the basketball ring, jumped off the mattresses and grabbed the

ring with both hands, swinging back and forth. The brick front of the garage gave way, causing the

deceased to fall to the ground and large groups of bricks to fall on him. The deceased stood up

and went inside but collapsed and died.


I adopt the recommendations numbered 1, 2, 3 and 6 made by the State Coroner in his finding

into the death of the late [deceased], Case No. 3457/97.

I further adopt the relevant part of the finding of the Deputy State Coroner in the inquest

concerning the death of the late [additional deceased], Case No. 1978/96, which was a death

relating to a ‘slam dunk’ at a basketball ring.

Evidence was given that there is no Australian Standard of direct application to this type of

equipment, unlike British Standard- B.S. 1982 Part 2 Section 2.7:1986 ‘Gymnasium Equipment,

Specifications for basketball and mini-basketball equipment.’

Accordingly, it is recommended that a specific Australian Standard be developed in order to

formalise construction of such equipment by giving design loads for such structures and

nominating permissible stresses and deflections. Failing the creation of a specific standard, it is

recommended in Australian Standard AS1924 Part 2- 1981 ‘Playground equipment for Parks,

Schools and Domestic Use’.



VIC.2009.2300


The deceased was a 23 year old Hungarian professional amateur boxer who had come to

Australia on a tourist visa, and had participated in three professional fights and 144 amateur

fights. On the day of the deceased’s death, he had been participating in a sparring session with a

fellow professional amateur boxer for an upcoming fight when he was struck in the head. The

deceased immediately became unconscious and was transported to hospital, but was unable to

be revived, despite a craniotomy to relieve intracranial pressure.


1. That there be a system of regulation implemented which requires:

a) Mandatory application for professional registration of boxers proposing to

participate in professional training or who are participating in sparring at a level

towards professional contest of with a professional boxer; and

b) Mandatory medical certification as to fitness to compete, including blood testing,

before a boxer participates in training or sparring at a level directed towards

professional contest or with a professional boxer and that such blood testing be

undertaken each 6 months.

c) Mandatory reporting of hospitalisation of any boxer of any status whether

professional or amateur, for injuries sustained whilst participating in training, or

sparring, or competition.

d) That the Boxing and Contact Sports Board implement a level of supervision upon

gymnasiums, when the training of boxers is occurring at a level directed towards

professional participation to ensure compliance.

2. I direct that a copy of this finding and recommendations be provided to the family of the

deceased, other interested parties; the Honourable Hugh Delahunty MP Minister for

Sport and Recreation; the Secretary, Department of Planning and Community

Development; the Registrar, Professional Boxing and Combat Sports Board (Victoria) for

the attention of the Board.



WA.2008.832


The deceased is a forty year old Indigenous prisoner, who had been incarcerated for 7 years and four months for armed robbery and grievous bodily harm. The deceased had a history of significant risk factors for ischemic heart disease, including diabetes and had complained of chest pains for some weeks prior. The deceased had been examined by a cardiologist and an appointment was booked for two weeks’ time for an angiogram. On the day of the deceased’s death, he had been playing football in the prison yard for around an hour when he suddenly collapsed. Efforts to revive the deceased were unsuccessful, and there was some confusion as to whether the deceased was breathing while undertaking observations of the deceased.


1. At this early stage in the implementation of ECHO I am anxious the progress notes aspect of the system ensures recording of contemporaneous medical investigations in an obvious manner. This will allow a proper updated and relevant history to be provided to external consultants and advise in-house doctors of the investigations which are currently being conducted with respect to individual prisoners.

2. The initiative by GRAMS to use Indigenous health workers in GRP be supported while accepting prison security is an issue which will always provide some tension with welfare issues. These need to be addressed.

3. I understand there is funding available for indigenous health workers via the Mar Mooditj Foundation. This is based on submissions from ALS on behalf of the deceased’s family. Unfortunately, I did not have the opportunity to hear from the Foundation in person. If a mechanism can be developed whereby security concerns are protected, I strongly urge prison authorities to work cooperatively with external sources of funding where possible. The use of Indigenous health workers where prisoners need to attend consultant reviews and ongoing investigations could be invaluable. This will ultimately contribute to the community as a whole by using the window of opportunity provided for input to indigenous health issues while indigenous prisoners are in custody.

4. Training with respect to calling a Code Red where there is a medical emergency which has not yet been defined be impressed upon prison officers.

5. Appropriate, adequate and ongoing CPR training be provided to prison officers and appropriate prisoners.

6. There be a clear direction to nurses attending medical emergencies they are to provide

leadership in the welfare arena, which will allow attending prison officers to appropriately concern themselves with security issues.



DATA SOURCES

Data on the NCIS has been provided by each State and Territory Coroner’s Office around Australia

and New Zealand. Additional codes are provided by the Australian Bureau of Statistics (ABS) and

Safe Work Australia.

ACT Coroner’s Court

MAGISTRATES COURT of

TASMANIA

CORONIAL DIVISION

NOTE: In some States/Territories the Coroner’s Office is part of the Magistrate’s Court.

FUNDING AGENCIES

Operational funding for the NCIS is provided by the following agencies:

Each State and Territory Justice/Attorney-General’s Department

Australian Department of Health

Australian Institute of Criminology

Safe Work Australia

Australian Competition and Consumer Commission

Australian Department of Infrastructure and Regional Development

The New Zealand Ministry of Justice

chambers of state coroner terry ryan · mechanism of fatal injury^ frequency percentage head trauma...

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