October 25, 2004
THE young man had been cleaning his dump truck, crawling between the raised dump box and the vehicle's frame. He hadn't noticed the nondescript but perilous cable by his left hand that could release the hydraulics that lifted the box.He accidentally brushed the so-called "over travel" cable, and the dump box fell down on him, crushing him instantly to death.
Graeme Johnstone, then deputy coroner of Victoria, presiding over the case, realised such an exposed cable, there to stop the truck toppling over if the dump box was raised at too great an angle, was a fatal design flaw. Twelve months later, however, there was another death in exactly the same circumstances, with that sinister cable again to blame.
Holidaying in the US that year, Johnstone called in at the US Department of Labor's Occupational Safety and Health Administration to look at some accident reports. What he saw stopped him dead in his tracks. There, on the latest report's front cover, were the details of a 25-year-old man who'd been killed by a falling dump box after disengaging exactly the same kind of cable by mistake.
That moment in the late 1980s is now likely to go down as one of the most monumental in the long quest to cut the toll of needless accidental deaths around the world. For Johnstone, unable to find out conclusively how many people had been killed in the same way, immediately convened a meeting of experts from Monash University. Together they articulated the need for some kind of information database so coroners around Australia would no longer look at each death coming before them in isolation, separate from tragedies that had happened in the past, in other states or overseas.

If, instead, they had the details of each death and its circumstances clearly logged and readily accessible, they realised, then coroners would be able to discern patterns of death and trends in fatalities. They would also be able to make far-reaching recommendations that could slash the number of such deaths in the future.
"The vast majority of so-called accidental deaths are preventable; there are very few non-preventable accidental deaths," says Johnstone, who has been Victorian coroner for the past 10 years. "That's a major part of a coroner's role: to identify as many factors as possible and look at those factors to see whether or not there are different ways of avoiding the consequences.
"We see constant repetitions of the same kind of accidents, yet as human beings we don't learn from them. The fundamental thing is to try and learn the lessons of death, and realise the potential we have for avoiding those deaths in the future. Putting the coroner out of a job should be the aim of every government agency."
Today that dream of a database has finally been realised and the National Coroners Information System is now giving every coroner in the country the chance to look at each death coming before them in its historical and geographical context. The project, a world first, is also being studied overseas, in the UK and New Zealand, where the judicial systems, as a result, are considering introducing the scheme and sharing data internationally. The system is based at the Victorian Institute of Forensic Medicine in Melbourne, where the Victorian coroner works. Its budget for 2004-05 is $750,000.
For most onlookers, it would be an obvious weapon in every coroner's armoury: to provide that link from the past to prevent future deaths or, as Canadian politician Thomas McGee said in the 1850s of the coroner's role, "speaking for the dead to protect the living". Yet those same tragedies keep on happening, with 12,000 to 18,000 deaths reported every year to coroners in Australia; 7500 to 8000 of those are accidental, or unnatural, deaths.
As long ago as 1487, an English coroner ordered that a cliff be fenced off because it had collapsed and caused a death. In 1990 in Melbourne the same thing happened in a beachside suburb, killing a three-year-old child; the same year in country Victoria, two girls died during a school abseiling expedition; and in Gracetown, Western Australia, a cliff gave way on a beach in 1995, taking nine lives.
The need for a data-collection and retrieval system was enunciated as long ago as in 1850s Britain, where the first coroner was appointed in 1194, principally to gather taxes for King Richard.
In the middle of the 19th century, Thomas Wakley, a surgeon, coroner and the first editor of the medical journal The Lancet, articulated the view that the office of coroner was "specifically instituted for the protection of the public" and needed the proper research tools, while holding inquests into deaths in the old workhouses. Yet it has taken more than 150 years – and another country in which there isn't even a federal coronial system – to finally institute such a system.
"It's not rocket science," says Johnstone, who stresses he has just been one of a wide-ranging team in starting the NCIS, which includes the Victorian Institute of Forensic Medicine, the Monash University Accident Research Centre, the Department of Epidemiology and Preventative Medicine at Monash, the Australian Institute of Health and Welfare, federal and state government agencies, and the offices of attorneys-general across the country.
"But in Australia, we are smaller, with a far smaller population and, while we have a number of different agencies involved with sudden and accidental death, they are manageable, they can talk to each other. In England, the number of deaths reported to the coroner is far greater.
"In Australia too, we tend to think, 'We've got a problem, let's work together and fix it. How can we overcome this? Let's have a go!' That's another difference." Now coroners across the country – and in Sheffield in England, where a coroner is trialling the system for its implementation there – can type a few keywords into the database and bring up all similar cases in order to discern patterns and reach conclusions about possible actions that may be needed to prevent future cases. With more than 70,000 deaths recorded on the database, which is funded by the state and federal attorneys-general offices, it has become a powerful tool.
For instance, Johnstone has been dealing with a case that involves a boating death, and has pulled up details of the 122 boating deaths that occurred in Australia between July 1, 2000 and June 30, 2004 – with the exception of some Queensland fatalities, since that state joined the system later than the rest. He's now hopeful that accidental deaths can be cut dramatically.
Design flaws in motor vehicles and trains that may have resulted in a number of deaths, like the Waterfall train disaster in Sydney, for example, can be pointed out and rectified; hospital and medical centres where deaths have occurred through mismanagement or error can be instructed on how to improve their methods; and roads and traffic systems can be made safer. With so much of Australia's industrial machinery and so many vehicles and products made overseas, we'll have an insight too into improving those to prevent deaths worldwide, and provide an early warning system.
Take the death toll from asbestos poisoning. Many of the recent deaths might never have happened if the lessons of past fatalities, where the risk from asbestos was documented as far back as 1898, had been taken on board, says Johnstone.
"So many 'accidental' deaths and injuries happening around Australia can be prevented," he says. "As well as those lives not lost, the savings would be in the billions of dollars. By simply identifying systems that are flawed or improving practices and procedures and the way we manage risk in our society, we can save so many lives.
"That's the important part of the coroner's role, the positive drawn from negative type of jurisdiction. We are hopefully giving something back by this, and giving something back to grieving families and individuals who will know that we've learned some lessons from the death."
Part of Johnstone's philosophy is that everyone makes errors every day, but that they shouldn't result in death. Systems should be in place to accommodate human error and, by shifting the emphasis in society away from focusing on blame and towards inquiring how an incident happened and how safety measures can be put in place, Australia could realise the potential for slashing the national accidental death toll.
"The database isn't perfect, it's a new product and a new idea in development, and we still have a long way to go," says Johnstone.
"But it's an important starting point and will, in time, prove tremendously important in reducing the number of accidental deaths around Australia."