Death Follows the Pattern, Not the Person

Every coronial report says it politely, but the message is blunt. These deaths were predictable, preventable, and structurally enabled. Recent findings from the Northern Territory and Western Australia show the same failures recurring with boring consistency, and 'boring' is the most dangerous word in safety.

This is not about freak accidents. It is about known risks left unmanaged until someone pays for them with their life.

The Northern Territory: Darkness, Distance, and Duty of Care

In Road Death 18 of 2024, the Northern Territory Coroner’s Court examined the death of a young woman struck while walking home from a licensed venue. She was intoxicated, walking in darkness on an unlit 80 km per hour road. None of that surprised the Coroner.

What mattered was what was missing. There was no courtesy transport condition on the liquor licence. There was no lighting between the venue and town. The risk was foreseeable, the exposure repeated, and the controls absent.

The Coroner explicitly recommended mandatory courtesy buses for similar venues and improved lighting where pedestrian movement is expected. That is not hindsight; that is overdue risk management.

This is the part the industry hates hearing. If you profit from people drinking in remote or semi-remote areas, you inherit responsibility for how they get home. Pretending otherwise is a legal strategy, not a safety one.

The Fatal Five Are Not a Slogan

Across multiple NT findings, the same contributors dominate the narrative. Alcohol or drugs. Speed. No seatbelt. Fatigue. Distraction.

In one case, an 18-year-old driver combined alcohol, excessive speed, and no seatbelt. The outcome was fatal. Again.

These are not behavioural quirks. They are high-energy transfer problems. Remove any one of those factors, and survivability changes dramatically. Leave all five unchecked, and the Coroner starts writing your eulogy.

Western Australia: When Help Cannot Hear You

Recent findings from the Coroners Court of Western Australia highlight a quieter but equally lethal issue. Communication failure.

In regional and remote WA, routine task updates through the OneForce system were delayed or missed due to poor connectivity. The Coroner noted that this impaired situational awareness and operational response, particularly where time and distance already work against you.

The finding went further. It pointed to low-earth orbit satellite systems as a practical solution for remote policing and emergency response. That matters because this is one of the rare moments where a Coroner is effectively telling agencies to stop pretending mobile coverage is good enough.

If your system assumes connectivity that does not exist, your system is lying to you.

Three Controls You Can Implement Without a Committee

First, venue-based transport controls. Courtesy buses are tied to licence conditions, not goodwill. The lighting design assumes that intoxicated pedestrians will not use it effectively. If your risk register does not explicitly name this, it is incomplete.

Second, remote communications redundancy. Satellite comms are no longer exotic or optional. If police, emergency services, or remote workers rely on app-based tasking, they need a pathway that works when towers do not.

Third, uncompromising vehicle controls. Seatbelts, speed governance, fatigue management, and zero tolerance for distraction. These are not personal choices once someone is at work or operating under a licence. They are system requirements.

The Safety Industry’s Uncomfortable Truth

None of this is new. The data is old, the recommendations familiar, and the funerals repetitive.

What changes outcomes is not another awareness campaign or poster about making good choices. What changes outcomes is forcing risk back into the system design, where it belongs.

Coroners do not write recommendations for entertainment. They write them because someone did not act when they had the chance.

The pattern is clear. The controls are known. The only variable left is whether organisations act before the next report adds another name to the list.

Blue pill or red pill...

SJ