Ravenshoe cafe fire inquest urges for better reporting
A Cairns inquest into the death of Nicole Nyholt and Margaret Clark in the 2015 Ravenshoe cafe explosion has led to a raft of recommendations towards educating medical practitioners about voluntarily notifying the Department of Transport about drivers with health issues.
Ms Nyholt and Ms Clark were two of the 19 people in the Serves You Right cafe in mid-2015 when a ute driven by 60-year-old Brian Scutt crashed in a 180kg gas cylinder at the cafe, sparking an explosion.
The women, aged 37 and 82, respectively, sustained significant burns and died in the days after being taken to hospital.
After a six-day inquest earlier this year, Coroner Nerida Wilson on Friday delivered her findings in the Cairns Coroner's Court where she said a number of gaps were identified in the collaboration between health and transport.
"It seems to me one of the sailing issues arising from this inquest is whether or not patient care can be better triaged and managed between systems," Ms Wilson said.
The court also heard that Mr Scutt had a history of seizures and dizziness dating back to 2004 and had ongoing medical appointments at the Atherton Hospital and with his GP leading up to the tragic day.
"Mr Scutt was lost to both the hospital system and his GP in respect of any long-term monitoring and treatment plan," Ms Wilson said.
"Every event that occurred was treated in isolation. In each of those occasions, it seems the GP was not immediately aware of the state of events."
The court also heard that Mr Scutt managed to "was selective in his reporting to all doctors and hospitals and his family" and was told numeroust times not to drive.
"The loss of connection between the hospital and his GP required Mr Scutt to become the conduit of his own care and treatment," Ms Wilson said.
"He disregarded the requests of his family not to drive and on three occasions did not adhere to medical practitioners' request not to drive."
Ms Wilson said that if his licence had been suspended or revoked in 2014, or if medical conditions had been endorsed on his licence, he may not have been driving on the day of the explosion.
"Of course, this is also speculative, noting Mr Scutt's wilful disregard over a period of 11 years of all advice not to drive," she said.
The coroner also said that it was not mandatory for Mr Scutt's treating doctors and his GP Dr Kenneth Connoloy to formally report Mr Scutt's condition to Transport and Main Roads.
Ms Wilson recommended that "peak bodies" in health and transport create an "inter-agency" working group led by the transport department to improve education about voluntary reporting.
The group would also include Queensland Health, Austroads, the Office of Health Ombudsman and a range of other medical organisations.
Ms Wilson recommended they "collaborate to develop an ongoing education and awareness campaign directed to all medical practitioners in Queensland".
"That such campaigns be specifically developed to educate those practitioners about the requirements to report patients directly to the state licensing authority in circumstances that are consistent with Austroads' fitness to drive guidelines."
In August 2019, Mr Scutt tragically died before the inquest started.
Originally published as Inquest urges for better reporting between health and transport