A coroner has found that an "undesirably steep disability car park" and a failure to effectively engage all of the brakes on a wheelchair contributed to the fatal fall of a 90-year-old woman.
The woman suffered fatal injuries when she fell from her wheelchair in the car park of Hobart Eye Surgeons in Argyle Street, in Hobart's CBD in December 2019.
In her report, coroner Olivia McTaggart said the woman had travelled to the eye surgeon in a taxi with her daughter.
The coroner heard they would usually get their taxi to park in the five-minute drop-off zone on Argyle street. However, on this day, it was full, so the taxi driver had to park in the clinic's car park, reversing into the "specifically marked disabled car park".
She noted that the woman's daughter had commented to the taxi driver that "she had concerns about going into the car park, due to it being steep".
The driver helped the passenger out of the car, partly releasing her from the straps that secured her within the taxi and wheeled her to a spot near the main building beneath a sign that stated "carers should seek assistance at reception" and had pictures of a wheelchair and walking frame.
In her report, the coroner noted "ambiguity and lack of clarity" regarding the signage in the car park.
CCTV shows wheelchair rolling away
Ms McTaggart observed that the woman was placed on "downward sloping land" and the taxi driver went to apply the brakes on the chair.
In evidence, the driver said he believed he had applied all of the brakes, however the coroner later found all of the brakes were not applied.
The taxi driver then unhooked the remaining straps securing the wheelchair to the taxi and returned to his cab to arrange payment for the fare with the woman's daughter.
From the CCTV footage, the coroner wrote, it appeared "the wheelchair began to move several metres down the slope".
Police investigators estimated that the woman travelled approximately 4 metres before she toppled out and landed on her left side.
Her daughter and the taxi driver then rushed to her side to help.
The 90-year-old was taken to the Royal Hobart Hospital and it was noted she was "alert and complaining of pain". There it was confirmed she'd suffered multiple bone fractures.
Her injuries were not operable and she was given pain relief. She died a few days later.
'No evidence' driver lacked experience or training
In her report, the coroner noted that the taxi driver had moved to Tasmania from Hong Kong in 2017 and he only had a basic understanding of English.
"Relevantly, in November 2019, I find that his lack of fluency in the English language and communication likely posed some impediment, at times, when situations demanded more complex communications with users of taxis," she wrote.
She said that, while it was unclear what training he'd received regarding the safe unloading of wheelchair users and applications of brakes, his experience "demonstrates an appreciation for the variations of wheelchairs and the safety of their users during his transportation".
"There is no evidence to suggest that [the driver] lacked the experience or training to safely transport and unload [the woman]," she wrote.
She also said it was clear the incident had significantly affected him and he stopped driving taxis in August 2021.
"I find that he was trying to assist the court in its inquiry and was not attempting to exaggerate or mislead the court in relation to circumstances surrounding [the woman's] fall," she wrote.
In her report, the coroner wrote that the woman was not wearing a seatbelt because she'd become agitated when staff had tried to secure it earlier.
The coroner said she could not make a finding that the failure to wear a seatbelt was a significant contributor to her fall and injuries.
However, she found there were multiple factors that caused her death.
The significant contributing causes were the fact that the wheel lock brakes were not applied to the wheelchair while "she was left unattended on a slope", the coroner wrote.
"She was unable, by virtue of her frailty and immobility, to protect herself from falling.
"Other circumstances [that] created this unfortunate situation included the lack of space in the drop-off zone, the undesirably steep disability car park and surrounds, the fact that [she] was not moved to a flatter space, and the fact that the fare was not paid [while] she was still in the taxi."
She noted that the eye surgery and property owner intended to improve the safety of the car park and recommended they finalise plans to "redesign and improved the safety of the car park for all users".
The coroner also recommended the surgery and its owner conduct a review of the "adequacy and efficacy" of the car park's signage.
