The partner of a man killed at Oallen Ford Bridge in 2015 broke down as inquest findings into his death were handed down on Tuesday.
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Melissa Pearce, accompanied by her late partner, James Hughes’ family, attended Glebe Coroners Court for the much-awaited findings. So too did Goulburn Mulwaree Council management and Mayor Bob Kirk.
Deputy State Coroner Teresa O’Sullivan found that Oallen Ford Road’s condition was a major factor in 50-year-old Mr Hughes’ death.
“The road’s surface should never have been allowed to deteriorate to the extent it did,” she said.
“On the basis of the evidence before this inquest, I also find that the condition of the surface of the northern approach to Oallen Ford Bridge Road on October 4, 2015 substantially contributed to the death of James Hughes.”
Mr Hughes, from Jerrabomberra, died after his Ducati motorbike struck a large pothole as he was riding east to the coast. His bike veered to the left, hit a guardrail and he was thrown over the bridge. Witnesses rendered first aid in vain.
Ms O’Sullivan identified numerous breakdowns in council road monitoring, reporting and complaint handling. The council had also conceded during the three-day inquest in Goulburn in December that it was aware of the pothole in the newly opened road but had not repaired it in a timely manner.
Critical emails containing motorists’ complaints about the pothole before Mr Hughes’ death had been directed to staff on leave.
Ms O’Sullivan found that no one had been appointed to act in then works manager Andrew Palmer’s role when he was on leave from September 25 to October 6, 2015.
This proved important as operations director Matt O’Rourke had forwarded an emailed complaint about the quality of road approaches to him from a motorist, Peter Dwyer, on October 1, 2015. It was marked ‘FY and action.’ Mr Palmer told the December inquest he only found this when he returned from leave.
“This demonstrates a systemic breakdown in Council’s communication system and (its) higher duty delegation system,” Ms O’Sullivan said.
“..This is not a situation where any one person is to blame or where one particular mistake or failure was made; there were a number of failures as described by (expert road witness) Mr (Greg) Wright and by witnesses in this inquest. It is the accumulation of these failures that ultimately let Mr Hughes down.”
Outside the court, Ms Pearce said she hoped the council learnt from the experience because “nothing would bring James back.”
Council general manager Warwick Bennett declined to comment but offered his reassurances to Ms Pearce and the Hughes family.
Ms O’Sullivan gave credit to the council for numerous system changes implemented since Mr Hughes’ death.