Coroners Act 1997 (ACT) ss 13, 34A, 52

1. On 22 May 2022, BK died at the Canberra Hospital ("TCH") after sustaining multiple injuries in a motorcycle accident on Bugden Avenue, Gowrie, in the Australian Capital Territory ("ACT") on the day before. At the time of his death, BK was 52 years old.

1. As BK's death appeared to be, for the purposes of section 13(1)(g) of the Coroners Act 1997 (ACT) ("the Act"), "directly attributable to an accident", it was reported to the ACT Coroner's Court on 22 May 2022.
2. Pursuant to section 13 of the Act, I am required to conduct an inquest into the manner and cause of BK's death. Section 52 of the Act outlines the findings I am required to make:
   1. Coroner's findings

(1) A coroner holding an inquest must find, if possible -

(a) the identity of the deceased; and

(b) when and where the death happened; and

(c) the manner and cause of death; and

(d) in the case of the suspected death of a person - that the person has died.

(a) must -

(i) state whether a matter of public safety is found to arise in connection with the inquest or inquiry; and

(ii) if a matter of public safety is found to arise - comment on the matter

1. I have chosen to publish my findings in this inquest as it is in the public interest to provide an accessible record of road accident deaths that occur in the ACT, so as to better facilitate consideration of road safety issues.
2. The timing of the publication of this category of findings will be affected by resource constraints that apply within the Court.

1. In making the findings that follow, I have considered the following materials:

(a) Police coronial report, dated 25 May 2022;

(b) Post-mortem report, dated 27 May 2022, prepared by Professor Johan Duflou;

(c) Mechanical inspection statement, dated 11 July 2022, prepared by the AFP Vehicle Inspection Team;

(d) Assessment report in relation to the road and environmental conditions of the relevant sections of Bugden Avenue at the time of the accident, dated 20 August 2024, prepared by the ACT Transport Canberra and City Services;

(e) BK's traffic records; and

(f) RTA evidentiary certificate, dated 1 August 2024, prepared by the Road Transport Authority.

1. On 21 May 2022, at some time in the evening, BK visited a friend's residence in Richardson ACT. By the time BK arrived at his friend's house, he was already intoxicated. During the course of his visit, he continued drinking and consumed at least two or three bourbon and cola beverages.
2. At some time in the evening, BK asked his friend if he could go for a ride on that friend's motorcycle, which was a red Kawasaki EX250 sports bike. The motorcycle had been unregistered since 2017. To BK's friend's knowledge, the motorcycle was "functional", but it had never been serviced.
3. Even though BK did not hold a motorcycle licence and was noticeably intoxicated, BK's friend agreed to let him take the bike out for a ride. She provided him with a helmet, which she advised had no functioning chin strap.
4. At approximately 2120 hours, BK set off on the motorcycle. He headed north on Bugden Avenue, towards the intersection with Ashley Drive. Bugden Avenue is a residential street with a posted speed limit of 60 kmh. It comprises one 4.5 metre traffic lane in each direction. The road surface, delineation, road markings, and road signs were reported to be in a good state of repair.
5. The section of the road where the accident occurred is relatively straight, followed by a gradual curve to the left. A bus stop is located on a gentle crest with good forward visibility.
6. As BK approached the curve, he appears to have lost control of the motorcycle. He veered across the oncoming lane and onto the grass verge on the eastern side of the road. Tire marks and damage to the scene indicate that BK struck a signpost at the bus stop, causing the motorcycle to slide on its side for about 7 metres before coming to rest. BK was thrown from the motorcycle during the collision.
7. The helmet BK was wearing was not secured to his head. It became dislodged during the crash. BK struck his head on the ground near the curb, which caused massive trauma to his head.
8. At about the same time, another driver was travelling along Bugden Avenue in the opposite direction. Upon nearing the crash site, he noticed the motorcycle lying on its side near the bus stop, with dust still in the air and BK's body nearby. The driver immediately stopped his vehicle, approached BK, called emergency services, and began performing CPR.
9. Ambulance paramedics arrived at the scene at a short time later. They continued with CPR and transported BK to the TCH. Despite their resuscitation efforts, BK's injuries were catastrophic. He remained in a deeply unconscious state and was admitted to the Intensive Care Unit, where he was treated for substantial blood loss and severe head trauma.
10. As revealed by a CT scan conducted at TCH, BK suffered extensive skull fractures, subarachnoid haemorrhage, and other critical injuries to his chest and spine. His injuries were assessed as unsurvivable, and BK died at a short time later, in the early hours of 22 May 2022.

1. A post-mortem examination was conducted by Professor Johan Duflou, forensic pathologist, on 27 May 2022. Professor Duflou identified injuries consistent with those identified at TCH. He formulated the cause of BK's death as "multiple injuries as sustained in a motor vehicle accident". I accept Professor Duflou's opinion.

1. Following the accident, the red Kawasaki EX250 sports bike was examined by the AFP Vehicle Inspection Team. The inspection indicated the motorcycle was in poor condition and "in desperate need of a service". Both the front and rear tyres were found to be non-roadworthy, with insufficient tread depths to provide adequate traction. The motorcycle had been unregistered since 2017, and there was no record of it being serviced during the intervening years.

1. Enquiries conducted with the ACT Road Transport Authority revealed that whilst BK was a holder of a valid Full Driver's Licence in the ACT, he had never held a Rider Class Licence in the ACT. In 1988, BK was issued with a Learner Rider Licence in NSW; however, he never obtained a Full Rider Licence in NSW.

1. BK's ante-mortem blood was sampled for toxicological testing at the ACT Government Analytical Laboratory. Results revealed the presence of significant intoxication, in the form of methamphetamine (0.44 mg/L) and alcohol levels (0.158 g/100mL), as well as the presence of cannabis (6 ng/mL) and various prescription medications. Collectively, these drugs are likely to have significantly impaired BK's ability to ride the motorcycle safely.

1. Investigations conducted by the AFP Major Collision Team and a Fatal Crash Callout Officer from Roads ACT suggested that BK was likely travelling at approximately 60-70 kmh at the time of leaving the road. The relevant section of Bugden Avenue was otherwise in good condition and well-lit by streetlighting. At the time of the accident, the weather was clear, and the road surface was dry. Investigators opined that BK's loss of control was likely due to a combination of excessive speed, heavy intoxication, and the poor mechanical condition of the motorcycle.
2. Notably, scrub marks on the curb and slide marks on the grass indicated that BK veered off the road before colliding with the signpost. The helmet, found several metres away from the crash location, displayed no visible signs of damage. It is likely the helmet had separated from BK during the collision, and his head had no protection when it struck the ground.

1. Having considered the evidence gathered during the inquest, I was satisfied that the manner and cause of BK's death were sufficiently disclosed, and, as such, a hearing was unnecessary.
2. On 20 February 2025, I communicated my decision not to conduct a hearing, and the reasons therefore to BK's family. They indicated that a hearing was not necessary and did not raise concerns as to the form of the provisional findings.
3. For that reason, in accordance with section 34A(1) of the Act, a hearing was formally dispensed with.

1. For the purposes of section 52(1) of the Act, I find:

That BK died on 22 May 2022 at the Canberra Hospital, as a result of multiple injuries sustained in a motor vehicle accident on Bugden Avenue, Gowrie, in the Australian Capital Territory.

1. I do not find any matter of public safety to arise in connection with the inquest into BK's death in respect of which comments should be made. The accident was likely caused by a combination of excessive speed, significant intoxication, an unsecured helmet, and the poor mechanical condition of the motorcycle. Each of those elements has a well-established and documented connection to diminished driving capacity, poorer vehicle performance and poorer injury outcomes when a collision occurs.

1. I extend my sincere condolences to BK's family. I acknowledge the grief his family and loved ones have endured as a result of his passing.

I certify that the preceding twenty-eight [28] numbered paragraphs are a true copy of the Findings of his Honour Coroner Archer.