CORONIAL LAW - Road accident, triple fatality - multiple injuries - referral to the Director of Public Prosecutions - no prosecution - findings as to manner and cause of death - decision not to conduct a hearing - publication of findings to establish a record of road related deaths

Coroners Act 1997 (ACT) ss 13, 34A, 52, 58

1. On 16 October 2022, Mohammad SHAHIDULLAH ("Mr Shahidullah"), Sultana RAZIA ("Ms Razia"), and Mohammad Sarowar Kawsir RONY ("Mr Rony") were passengers in a red Toyota Yaris ("the Yaris") being driven by Anwar JAHID ("Mr Jahid"). Mr Jahid was the son of Mr Shahidullah and Ms Razia, and the brother of Mr Rony.
2. At approximately 1445 hours the Yaris was headed south on John Gorton Drive, Whitlam in the Australian Capital Territory ("ACT") when it collided with a Toyota HiAce ("the HiAce") being driven in the opposite direction by Mr SU[1].
3. Mr Shahidullah, Ms Razia and Mr Rony died at the scene from injuries sustained in the accident. Mr Jahid survived the accident but sustained severe physical injury and traumatic brain injury. The driver of the HiAce, Mr SU, suffered injuries resulting in permanent scarring.
4. The evidence arising from a police investigation into the collision indicates that Mr Shahidullah suffered a medical emergency associated with Type 1 diabetes mellitus immediately prior to the accident. In a panic, and with the intention of obtaining medical help for Mr Shahidullah, Mr Jahid drove the Yaris at speeds that ultimately led to him losing control of the vehicle and crashing into the HiAce.
5. I shall with respect, and where appropriate, refer to the deaths of Mr Shahidullah, Ms Razia and Mr Rony as "the deaths".

1. The deaths were reported to the ACT Coroner's Court on 17 October 2022, as they fell within the terms of section 13(1)(g) of the Coroners Act 1997, being deaths that "[appear] to be directly attributable to an accident".
2. I was required to hold an inquest[2] into the manner and cause of their deaths and make findings that are required by section 52 of the Act. That section of the Act relevantly provides:

(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. The Australian Federal Police conducted an investigation into the circumstances of the deaths as part of a broader investigation into whether Mr Jahid had committed criminal offences involving the manner of his driving prior to the accident.
2. It was established from that investigation that Mr Shahidullah, Ms Razia and Mr Rony arrived in Australia from Bangladesh on 25 September 2022. They travelled on tourist visas, for the purpose of visiting Mr Jahid and his wife. Mr Jahid and his wife were also from Bangladesh and had gained Australian permanent residency in 2021. Mr Shahidullah was an insulin-dependent diabetic, and it is unclear whether he brought insulin with him.
3. The red Toyota Yaris contained several medium sized suitcases, and other bags packed with clothing and snack foods, consistent with preparation for travel. The bags had been removed from the vehicle prior to Police arrival. The suitcases were tagged with Malaysia Airline luggage tags in the name of "Razia Sultana" indicating arrival in Australia via Sydney on 25 September 2022.
4. In the early afternoon of Sunday 16 October 2022, Mr Jahid was driving the Yaris westward along William Hovell Drive in Whitlam, ACT. There were three passengers seated in the Yaris. Mr Shahidullah sat in the rear seat on the driver's side, Ms Razia sat in the rear seat on the passenger side, and Mr Rony sat in the front passenger seat.
5. Mr Jahid held an active Provisional 2 NSW driver's licence. He had held a provisional licence since April 2022.
6. At approximately 1440 hours, Mr AP and Ms CT saw the Yaris and its occupants to be parked at the intersection of William Hovell Drive and Coulter Drive. Witness statements were obtained by police from Mr AP and Ms CT. I summarise the relevant content below.
7. Mr AP:

...I slowed down and at that intersection there was already a red hatchback that was stationary and waiting for the lights to turn green. [W]hile we were waiting, the front passenger stepped out...opened the car boot and took out...a packet of Oreos and tried to hand it over to his backseat passengers. ...

[A]fter that I heard a short yell or scream. ... I then drove around and had a look, and realised it actually may be a medical distress. ... I said, 'Do you need any help?' And the driver said, 'Ambulance.' ...[S]o I said, 'Do you want an ambulance here[?]' And then... instead of then saying yes, he said, 'Hospital.' ... I then pointed in the direction of Calvary. ... Even in communicating with them, I could see they were very panicked.

...[T]hey seemed to have a lot of luggage and a lot of belongings in the boot. ...

...[T]hey weren't willing to wait for an ambulance. They just wanted to go.

...[A]round the car there seemed to be... newly thrown or dispersed items. ...

... [I]t appeared that the person in the front passenger seat had gotten out of their car and ...there was something going on between the front ... and the back passenger person.

... [I]t definitely seemed that there had been some kind of conflict going [on] in the red car or maybe someone who was sick...

1. I accept that Mr Shahidullah had become very unwell and may have been unconscious in the rear of the vehicle. Mr Jahid and Mr Rony were outside the vehicle and in an apparent state of panic, trying to help their father. Mr AP got out of his vehicle to assist and had a conversation with Mr Jahid. During that conversation, Mr Jahid said the words 'ambulance' and 'hospital'. Mr AP offered to lead the persons to North Canberra (Calvary) Hospital and Mr Jahid nodded in agreement, but before Mr AP could return to his vehicle, Mr Jahid hurriedly got back in his vehicle and drove west on William Hovell Drive, turning south on John Gorton Drive, Whitlam in the ACT.
2. Before the car departed, Ms CT and Mr AP observed items being removed from the rear and back seat of the car and left near the roadway. It appears the items were removed to create space for Mr Shahidullah to lie down. The items remained at the spot until recovered by the police.
3. Investigating police have evaluated what directions are produced by GPS-based map programs at that location when different words are entered as the destination. There were differential outcomes depending on the words used. The nearest hospital from that location was North Canberra (Calvary) Hospital. However, it may be that that Mr Jahid had used words that caused directions to The Canberra Hospital ("TCH") to be produced. That was generally the direction in which Mr Jahid headed.
4. Shortly after, at about 1445 hours, Mr SU was driving the HiAce north along John Gorton Drive, Whitlam, in the ACT. John Gorton Drive is a duplicated, arterial road that runs primarily north to south connecting the Molonglo Valley area to the district of Belconnen.
5. John Gorton Drive changes into Coppins Crossing Road just south of the Hazel Hawke Avenue traffic signals and sometimes the relevant road area is described as Coppins Crossing Road.
6. As the Yaris was travelling south along John Gorton Drive, the vehicle entered into what is known as a "yaw" (which involves a car turning around its vertical axis), rotating clockwise. This happened at the 'Form One Lane' merging point after the intersection with Hazel Hawke Avenue. The Yaris crossed the unbroken white lines delineating the north and south bound lanes where they meet just after the painted island and entered the path of the HiAce. The two vehicles collided in a head on collision, the area of impact being within the north bound lane. There is a slight bend in the road at that point (curving to the right) which may have influenced the movement of the Yaris into a yaw. The curve would be comfortably negotiated at a speed within the speed limit.
7. As a result of the collision, the HiAce rotated counterclockwise and came to rest across the north bound lane of John Gorton Drive, with the rear of the vehicle near the centre line markings and the front of the vehicle on the grass at the outer edge of the roadway. The HiAce sustained major front-end damage.
8. The Yaris rotated counterclockwise and came to rest on a grassy embankment beside the north bound lane of John Gorton Drive facing towards the roadway. The Yaris also sustained major front-end damage, partially collapsing the driver and front passenger cabin space.
9. Mr SU was completely without blame for the collision. There was nothing he could have done to avoid the oncoming car.

1. The weather at the time of the collision was clear and sunny, and the temperature was about 18 degrees Celsius.
2. The road surface was dry and in good repair around the area of the collision. The roadway had undergone upgrades and duplication, except for a portion that spans between Holborow Avenue in Denman Prospect and Hazel Hawke Avenue in Whitlam. The road surface, was comprised of a bitumen surface and a short section of reseal, and associated line marking, and retro-reflective pavement markers (which were in good condition). There was gravel on the median and hard shoulder adjacent to the crash site, but the line of travel of the Yaris did not see it enter these areas.
3. The remaining section of John Gorton Drive between these intersections merges from a dual carriage to a single lane in each direction, divided by double unbroken white lines. While the speed limit on most of John Gorton Drive is 80km/h, the speed limit where the collision occurred was signposted at 60km/h.

1. At 1447 hours, a member of the public called 000. The ACT Ambulance Service ("ACTAS") arrived first at the scene followed shortly by the ACT Fire Brigade ("ACTFB"). The AFP arrived shortly after.
2. Mr Rony was found seated in the front passenger seat. It is clear that he had not been wearing a seat belt at the time of the collision. He could not be removed from the car due to crush damage to the portion of the car in which he was seated. He was clearly deceased.
3. Mr Shahidullah (rear seat, drivers' side) and Ms Razia (rear seat, passenger side) were removed from the car and placed in a grassy area nearby for further assessment by ACTAS. It was soon evident that both were deceased.
4. Ms Razia was wearing a seat belt with a sash across the chest. The evidence suggested Mr Shahidullah was wearing a seat belt in some fashion, possibly across the lap but without the chest sash.
5. Police assisted ACTFB in removing the roof of the vehicle, and extracting Mr Jahid, who received medical attention at the scene before being transported to TCH by ACTAS.
6. Mr SU had removed himself from the HiAce before the arrival of emergency services. He received serious injuries as a result of the collision and was transported to TCH by ACTAS.
7. At about 1600 hours a Forensic Medical Officer ("FMO") attended the scene and conducted an examination of the three deceased persons and pronounced life extinct.

1. Mr SU sustained a transverse fracture of the distal third of the right ulna, being the right forearm, resulting from high impact blunt force trauma in keeping with the forces generated in a motor vehicle collision. The injury required surgical intervention, with the surgical wounds resulting in permanent scarring.
2. Mr Jahid suffered a severe brain injury from the collision. Imaging of his brain at TCH showed multiple haemorrhages and an MRI showed diffuse axonal injury. He also suffered multiple fractures which required surgery. He remained in hospital until July 2023. He suffers permanent disabilities as a result of the accident, including a reduction in cognitive capacity and permanent compromise of his mobility. Collectively the injuries will require lifetime disability supports.

1. At my direction, forensic pathologist Professor Johan Duflou performed post-mortem examinations on Mr Rony, Ms Razia and Mr Shahidullah on 18 October 2022. CT technology was used in each of the three examinations.
2. In respect of Mr Shahidullah, given the history known to investigating police, a full internal examination was conducted and included toxicology and biochemistry. The following passages appear in Professor Duflou's post-mortem report in respect of this death:

At autopsy, the deceased was found to have a large number of injuries to the surface of the body, typical of a motor vehicle collision. Extensive internal injury was identified on CT scan, including injury to the head, chest and abdomen, and there were also pelvic, bilateral upper limb, and left lower limb injuries. No unexpected injuries were identified. With reference to natural disease processes, the deceased was noted to have a degree of coronary artery narrowing but not generally felt sufficient in severity to result in an acute cardiac event. Fatty infiltration of the liver, and changes in the kidney are very likely diabetes related. A urine test revealed the presence of a very high level of glucose and scanty ketones, while a vitreous fluid biochemistry test returned typical non-diagnostic postmortem values. No specific changes of severe diabetic ketoacidosis were identified on kidney microscopy. Toxicology revealed the presence of oral antidiabetic agents only.

The deceased has sustained severe injuries which can be expected on their own to be sufficient to cause death. There are also injuries such as fracturing of forearm bones, suggestive of the deceased attempting to brace prior to the crash, which would suggest he was at least semiconscious at the time of the crash. Internal bleeding similarly indicates the deceased was alive at the time of the crash. Natural disease in the form of likely marked hyperglycaemia secondary to diabetes was identified on the basis of urine testing, and there was a degree of heart, kidney and liver disease all typical of diabetes. I conclude that partial incapacitation as a result of diabetes appears possible on pathological grounds and witness observations appear to support this. It appears unlikely the deceased was having a primary cardiac or cerebrovascular incapacitating event immediately preceding the crash.

1. The cause of death given in each case was multiple injuries with a range of internal injuries causing bleeding and fractures being identified by CT scan.
2. In respect of Mr Shahidullah, a condition said to have contributed to death was "Diabetes Mellitus with Hyperglycaemia". Hyperglycaemia means high blood glucose levels (blood sugar levels). It can affect people with diabetes. Factors leading to hyperglycaemia include not taking enough glucose-lowering medication or insulin. Clinically, a person who is suffering from severe hyperglycaemia can have a range of symptoms, including loss of consciousness. Severe hyperglycaemia resulting in unconsciousness is considered a medical emergency and is generally initially treated by ambulance at the scene followed by emergency department continuation of treatment. For an untrained person administering care the recommended approach is general supportive treatment such as keeping the airway clear. Calling for assistance from emergency services is essential. When the nature of the episode is unknown and the person is conscious, it is a reasonable response to administer food or drink that might raise glucose levels. In the setting of hyperglycaemia, the marginal but further raising of glucose levels that may therefore result would not have a significant detrimental effect.

1. The two vehicles involved in the collision were uplifted by the AFP and transported to the Road Policing Centre for the purpose of mechanical examination. The mechanical examination on the Yaris was significantly constrained by the amount of damage that had been occasioned by the collision. It was not possible to determine if there was a mechanical condition or defect that may have contributed to the collision.
2. The examination that could take place suggested the Yaris was in a good condition.

1. On 17 October 2022, Police from the ACT Police Major Collision Team ("ACTP MCT") used Crash Data Retrieval ("CDR") software to download the event data record ("EDR") from the airbag control module ("ACM") which had been previously removed from the HiAce.
2. The ACM is the module in the vehicle that determines when the airbags deploy in the event of a collision. To do this it uses a variety of sensors that collect and save information that can be retrieved after the collision. An analysis of this EDR showed that 5 seconds prior to the airbag being deployed, the HiAce was traveling at marginally above the posted 60km/h speed limit.
3. I reiterate that Mr SU's driving did not contribute to the cause of the accident.
4. On 26 October 2022, Police from the ACTP MCT used the CDR software to download the EDR from the ACM which had been previously removed from the Yaris. An analysis of this EDR shows that 5 seconds prior to the airbag deployment time, the Yaris was traveling at 150km/h in the 60km/h zone.

1. A mandatory blood sample was taken from Mr Jahid when taken to TCH. Results of that sample were negative to alcohol and prescription drugs.

1. The Yaris was searched by the AFP. Medications were found some of which, it can safely be said, belonged to Mr Shahidullah. Some of those medications were insulin medications associated with the treatment of diabetes. These hyperglycaemic medications would have lowered the level of glucose and, if ingested may have improved Mr Shahidullah's condition.
2. The evidence available to me suggests Mr Jahid knew his father had diabetes. It is less clear whether he was aware as to how the condition affected his father, how it was being medically treated, what medication his father was taking and what had caused the episode that became manifest in the car.

1. The location of the accident has been the subject of substantial re-configuration. An analysis of the scene at the time suggested that permanent speed limit signs may have been missing but that several temporary signs were present on John Gorton Drive, including a southbound 60km/h 'roadworks' sign.
2. In addition, two chevrons indicating a change in road direction were missing, seemingly due to damage caused by cars passing along that part of the road.
3. It is unlikely, given the speed that the Yaris was travelling, that these issues were relevant to the cause of the accident.

Mr Shahidullah's Condition Prior to the Accident

1. While it is not possible to be conclusive about Mr Shahidullah's condition prior to the accident, I find that, having regard to:
   1. the observations of witnesses as to his state of unconsciousness;
   2. the distress of the occupants of the car;
   3. his medical history;
   4. the medications found in the car; and
   5. Professor Duflou's autopsy finding and opinions,

it is more probable than not that he suffered a hyperglycaemic episode when he was a passenger in the car being driven by Mr Jahid. It is also probable that Mr Jahid was attempting to transport Mr Shahidullah to a hospital in circumstances where Mr Jahid perceived there to be a medical emergency. The course Mr Jahid took may have been based on an erroneous assumption that TCH was the nearest hospital from the point where he stopped to speak to Mr AP and Ms CT.

1. Section 58 of the Act provides a mechanism by which cases that might involve the commission of indictable offences can be referred to the Director of Public Prosecution ("DPP") for consideration of whether someone should be charged. Mr Jahid's manner of driving gave rise to the possibility that he had committed offences, including culpable driving causing death contrary to section 29(7) of the Crimes Act 1900. By letter dated 6 December 2022 the deaths were referred to the DPP for consideration of whether prosecution action should be taken in relation to the conduct of Mr Jahid. At that stage, the investigation of the deaths was not complete.
2. A full brief of evidence was prepared and submitted to the DPP.
3. On 9 February 2024, the AFP were informed that no charges would be brought. That advice was relayed to the Court on 13 February 2024.
4. It is not open for this Court to canvass or assess the DPP's reasons for deciding not to bring charges. However, it is apparent that the medical condition Mr Shahidullah suffered at the time of the collision was a factor that was considered important in the context of determining:
   • whether the elements of the charge of culpable driving had been made out;
   • whether the defence of a defence of sudden or extraordinary emergency set out in section 41 of the Criminal Code 2002 might have been available at trial; and
   • whether, in light of all the circumstances of the case and Mr Jahid's catastrophic injuries the prosecution of Mr Jahid was in the public interest.

1. Pursuant to section 34A of the Act, I am able to dispense with a hearing if I am satisfied that the manner and cause of death are sufficiently disclosed and a hearing is unnecessary. I was so satisfied. The information available to me to make the findings I had was not likely to be meaningfully elaborated by requiring witnesses to attend to give oral evidence.

1. On 2 October 2025, copies of my provisional findings were forwarded to Mr Jahid and he was given the opportunity to make submissions in respect of the (implicit) criticism made of his manner of driving before the collision. Section 55 of the Act required me to invite Mr Jahid to make a submission or give a statement to me about the proposed comments. Mr Jahid made a submission. The effect of the submission made was that he had no independent recollection of the crash and the events immediately before it. Although he raised suggestions as to matters that in his view required further investigation he did not directly challenge the factual basis of the findings that were proposed. I have considered his submission and have taken it into account.

1. Pursuant to section 52 of the Act I find that Mohammad Shahidullah, Sultana Razia, and Mohammad Sarowar Kawsir Rony died on 16 October 2022 of multiple injuries sustained in a motor vehicle accident that occurred on John Gorton Drive, Whitlam, in the Australian Capital Territory. In respect of Mohammad Shahidullah, I find that a condition said to have contributed to death was "Diabetes Mellitus with Hyperglycaemia".
2. I do not find a matter of public safety arises from the deaths.

1. I express my condolences to the family of the deceased. The deaths were an unspeakable tragedy.
2. I apologise to the family for the delay in finalising my inquest.

I certify that the preceding sixty-three [63] numbered paragraphs are a true copy of the reasons for findings of his Honour Coroner Archer.

[1] I have made orders assigning pseudonyms to all witnesses and persons involved in the investigation save for the deceased people and driver of the vehicle.

[2] Under the Act, meaning given to the term "inquest" varies. In this context it means a process of investigation. There can be a "hearing" for an inquest.