An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide and Port Augusta in the State of South Australia, on the 11^th and 12^th days of October 2007, and the 9^th day of November 2007, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Martin Craig Pudney.

The said Court finds that Martin Craig Pudney aged 30 years, late of 48 Tasman Avenue, Flinders Park died at Echo Camp Track, Arkaroola, South Australia between the 12^th and 15^th days of January 2005 as a result of exposure.  The said Court finds that the circumstances of his death were as follows:

1.                  Introduction

1.1.           Martin Craig Pudney was born on 5 May 1974.  He was 30 years of age at the time of his death which occurred between 12 and 15 January 2005.  His body was discovered on a track leading to Arkaroola Springs at about 5:00 pm on Saturday 15 January 2005.  A post mortem examination was carried out by Dr Allan Cala who gave the cause of death as “consistent with exposure”.

1.2.           According to a statement provided by Mr Pudney’s mother, Jennifer Pudney[1], Mr Pudney was in good health although he had a few minor ailments from playing sport over the years.  He was a quiet unassuming man who had a good job and tertiary qualifications.  He was a draftsman.  His mother described him as a very conservative fellow who did not draw attention to himself.  His mother said that he owned a Nissan X-Trail motor vehicle which he had purchased approximately three months before his death.

1.3.           It appears from the evidence heard at the Inquest, and from the various statements obtained in the course of the investigation, that Mr Pudney was travelling in the Nissan X-Trail on or around 12 January 2005 in and around the Arkaroola Wilderness Sanctuary in the Flinders Ranges.

2.                  Mr Douglas Sprigg

2.1.           Mr Douglas Sprigg is the Director of Arkaroola Village, a tourist motel, and he oversees the running of that establishment.  He gave evidence at the Inquest and it appears that he was the last person to see Mr Pudney alive.  He explained that Arkaroola is situated in the north Flinders Ranges which is (geologically) one of the oldest parts of the ranges, with many deep secluded gorges.  The Arkaroola Wilderness Sanctuary is run in much the same way as a national park would be.  The sanctuary is of interest to campers and four-wheel drive enthusiasts, containing a number of tracks which are suitable for use by four-wheel drive vehicles.  Arkaroola is open all year round, but visitor numbers drop off in the summer months.  According to Mr Sprigg in the months of December, January and February the sanctuary experiences temperatures as high as 46 degrees with particularly high UV levels.

2.2.           One of the most popular of the four-wheel drive tracks in Arkaroola is a track known as the “Echo Camp Backtrack”.  It was on this track that Mr Pudney’s Nissan X-Trail vehicle was found, having apparently been abandoned by him.  It was found approximately seven kilometres from where his body was later discovered.

2.3.           Mr Sprigg said that the Echo Camp track includes some very steep slopes for which a four-wheel drive vehicle is required.  He said that it is possible to take the lighter, recreational four-wheel drive vehicles such as the Nissan X-Trail over the track but that the management at Arkaroola recommend that it only be traversed by heavy duty four-wheel drive vehicles[2].

2.4.           Mr Sprigg stated that there is no mobile telephone coverage in Arkaroola.  Communication is by means of UHF radio.

2.5.           Mr Sprigg was the last person known to have seen Mr Pudney before his death.  In his original statements to police Mr Sprigg put this encounter as having taken place in the early afternoon of 13 January 2005.  However, having considered certain photographs recovered from Mr Pudney’s digital camera, which bear date imprinting, Mr Sprigg was less certain at Inquest and said that the encounter may have occurred in the early afternoon of 12 January 2005.  Mr Sprigg made the general observation that Mr Pudney struck him as a pleasant man with a happy disposition.  The encounter took place in the business centre at the Arkaroola Village.  Mr Pudney’s vehicle, the Nissan X-Trail, was parked outside the building.  Mr Pudney and Mr Sprigg spoke to one another in the main entrance to the building.  Mr Pudney was asking what he could look at and where he could go within the sanctuary.  Mr Sprigg asked if he had a four-wheel drive and Mr Pudney pointed out the Nissan X-Trail.  Mr Sprigg advised Mr Pudney of some of the tracks suitable for two-wheel drive vehicles.  He told him of the Echo Camp track but said that there were certain parts of it which were a bit hazardous.  Mr Sprigg advised that Mr Pudney should take a UHF radio with him, which Mr Sprigg could supply, if Mr Pudney intended to take that track.  Mr Pudney replied that he was going to Wilpena that night.  Mr Sprigg took this intimation to indicate that Mr Pudney was declining the use of the UHF radio, and therefore assumed that Mr Pudney had elected not to tackle the Echo Camp track.  Mr Sprigg gave Mr Pudney an outline of the geology of the area and the discussion ran for about ten minutes.  Although his recollection is now somewhat hazy, Mr Sprigg recalled that Mr Pudney showed some interest in the details of the region he was able to impart.  Mr Sprigg’s impression was that Mr Pudney had not been to Arkaroola before.  Mr Sprigg formed the view that Mr Pudney was a sensible person who knew his limits.

2.6.           Mr Sprigg said that that the next he heard of Mr Pudney was on the night of Friday, 14 January 2005 at approximately 9:30 pm when some German tourists returned to the village after having been out for the day.  Mr Sprigg approached them to enquire why they were so late.  They explained that they had encountered a vehicle on the way and had spent three hours building a track around the vehicle.  They had been travelling the Echo Camp Backtrack.  They gave a description of the vehicle which accorded with the Nissan X-Trail being driven by Mr Pudney.  Mr Sprigg immediately became concerned for Mr Pudney’s welfare and asked the tourists if they had seen Mr Pudney.

2.7.           Mr Thomas Kreutziger, a visitor from Germany, gave a statement on 15 January 2005 which was admitted as Exhibit C7c.  He said that he was from Germany and was currently holidaying in South Australia.  At about 5:30 pm on 14 Januarys 2005 he was with Lilli Mixich driving on a track near the Arkaroola Village.  They found a Nissan X-Trail in the middle of the track and could not pass because the track was quite narrow.  They got out of their vehicle and could not find anyone with the Nissan X-Trail.  They thought the car smelt as if the clutch had burnt out[3].  The driver’s side door and the back rear door of the vehicle were unlocked.  While looking for the driver, they walked to the top of the hill on which it was stopped.  They called out to try to attract the driver’s attention for approximately an hour with no result.  At the top of the hill they noticed a set of golf clubs and a barbeque which was still in its carry case.  They took these to the Nissan X-Trail on the assumption that they had come from that vehicle, and placed them in it.  They borrowed a small shovel from the Nissan X-Trail and spent a couple of hours digging a detour on which to bypass it.  They did not see any person during this period.  They then drove back to Arkaroola along the main track and did not see any other vehicles or people.

2.8.           Mr Sprigg gave evidence that he called the Leigh Creek Police Station at approximately 9:30 pm, or soon after his conversation with Mr Kreutziger.  The telephone was not answered at Leigh Creek Police Station but was diverted to the Port Augusta Police Station and answered by a female person.  Mr Sprigg could hear that there was a considerable amount of activity taking place in the background during his conversation with this female and that she appeared to be distracted.  He told her that he was strongly concerned about a missing person and wanted to speak to the police at Leigh Creek so that he could obtain their advice about what action he should take.  Mr Sprigg reasoned that as the German tourists had recently travelled the track they would not have missed Mr Pudney if he had been anywhere along its length.  He understood that the female police officer would institute an appropriate response.

2.9.           Having heard nothing further, he rang again the Leigh Creek Police Station number at 11:30 pm and was again diverted to the Port Augusta Police Station, and again spoke to a person whom he believed to be the same female police officer.  He reiterated the urgency of the situation and gave his home telephone number in the expectation that he would receive a telephone call from the police during the night to discuss the matter.  He said that he did not set his alarm clock because he expected that his sleep would be interrupted by a telephone call from the Leigh Creek police.

2.10.       Mr Sprigg said that he was not contacted by the police that night and slept through until 8:00 am.  He then telephoned the Leigh Creek Police Station again and was diverted to the Port Augusta Police Station once more.  He spoke with another female police officer and explained that he had called twice the night before, and the nature of those calls.  He said that the police officer to whom he spoke seemed concerned to the point of anger that she had no record of the calls having been made the night before.  Mr Sprigg said that from that point on his concerns were acted upon expeditiously by the police.  Shortly after this telephone call, he made a call direct to the Leigh Creek Police Station and spoke to Sergeant Harris.  It was apparent that Sergeant Harris had already ascertained the identity of the registered owner of the Nissan X-Trail from the registration number which Mr Sprigg had provided on each of the three occasions on which he had telephoned the police.  Sergeant Harris stated that he would come up to Arkaroola with the local State Emergency Service unit as quickly as possible.  Mr Sprigg suggested that he fly around the Arkaroola tracks in his own aircraft – it was a 1930’s aircraft which could fly slowly at low altitude.  Sergeant Harris agreed to this course of action.  Mr Sprigg thought that there would be little chance of finding Mr Pudney if he had moved away from the tracks any significant distance because of the vegetation.  Mr Sprigg saw nothing during his flight and was unsuccessful in making contact with the police by radio from his aircraft.  Upon landing, he drove a vehicle along the Echo Camp track and saw no sign of Mr Pudney.

2.11.       I should say that I found Mr Sprigg to be an extremely impressive witness.  He was very diligent and conscientious in his actions on 14 and 15 January 2005, and subsequently.  His general conscientiousness was evident in the way in which he gave evidence.  I accept entirely his evidence in all respects, acknowledging his own uncertainty about the date of the encounter with Mr Pudney.  That uncertainty was, I am sure, due to the fact that Mr Sprigg would have attached little or no significance to the encounter at the time it occurred, and had misplaced his recollection of the day on which it occurred when he thought about it subsequently.

2.12.       Mr Sprigg made significant efforts in the months following the discovery of Mr Pudney’s body to attempt to reconstruct what may have occurred.  As I have already stated, he became aware of certain photographs which had been taken by Mr Pudney on his digital camera.  Mr Sprigg was shown those photographs by Mr Pudney’s brother, Richard Pudney.  Mr Sprigg attempted to determine the points at which the photographs must have been taken.  He did this in conjunction with Mr Richard Pudney.  Subsequently, Mr Sprigg traversed the Echo Camp track and took certain measurements with a GPS and an inclinometer, a device that is used for measuring the steepness of particular inclines.  The inclinometer was placed upon a straight length of wood approximately two metres in length to provide an “average” indication of the slope of the track.  Using this device, Mr Sprigg ascertained that the angle of incline of the slope up which the Nissan X-Trail was travelling when it came to rest was 18.8 degrees up slope.  The Echo Camp track is a one-way track, and Mr Pudney’s Nissan X-Trail was found facing the correct direction for travel on the track.  Mr Sprigg carried out tests of the angle of incline of slopes that would have been encountered by Mr Pudney prior to the slope upon which his vehicle came to rest.  A number of those slopes were significantly steeper than the one at which the Nissan X-Trail was found, including slopes with degrees of incline of 23 degrees, 25.9 degrees, 26.4 degrees, 25.2 degrees and 20.9 degrees.  Mr Sprigg stated that in his opinion the points of difficulty upon the track had been traversed by Mr Pudney before he came to the place at which the vehicle was later found.  This was not a place, according to Mr Sprigg, that he would have expected Mr Pudney have encountered difficulty.  The previous slopes and places he had traversed were far more difficult.

2.13.       When Mr Sprigg reached the Nissan X-Trail on the morning of Saturday, 15 January 2005 while searching by vehicle after his aircraft flight, he noted that the Nissan X‑Trail contained a moderately full 10 litre water cask on the front passenger seat.  He noted that the vehicle did not appear to be stuck and he could not detect any smell from the clutch.  The clutch pedal felt normal.  It was Mr Sprigg’s preliminary view that the vehicle could have successfully traversed the slope.  Mr Sprigg noted minor evidence of wheel spin on the front right wheel and less on the left rear wheel.

2.14.       Mr Sprigg decided to continue beyond the abandoned vehicle in the reverse direction in the hope of finding some evidence of Mr Pudney.  He looked for footprints in any areas where they might have been preserved and diverted to the Bararranna Gorge and waterhole where he found no footprints or other signs of human activity.  He found some possible footprints on the Arkaroola Creek Crossing about 1.5 kilometres before Echo Camp Waterhole.  He notified Arkaroola where Sergeant Harris had arrived.  He drove to Echo Camp to check that Mr Pudney was not there and detoured to the Arkaroola Waterhole where he found nothing.  Upon his return to Arkaroola he spoke with Sergeant Harris and briefed him.  A briefing was conducted with the State Emergency Services crews, at which Mr Sprigg advised the position of possible footprints as noted by him and information relating to tracks and waterholes.  Crews were to use UHF Channel 8 duplex while west of the abandoned vehicle and were to call Beverley Uranium Mine on Channel 30 when east of the higher ranges.  Mr Sprigg suggested that a gentleman by the name of Christian Coulthard who has exceptional tracking skills might be brought into the search.  This advice was acted upon by police.  Mr Sprigg also suggested that Ryan McMillan, an employee of Arkaroola might be deployed in the search as well because of his extensive knowledge of the region.  However, Mr McMillan’s driver’s licence had been suspended at the time, and Mr Sprigg informed Sergeant Harris that he would have to be given permission to engage in the search.  Sergeant Harris thought that it would be acceptable in the circumstances for Mr McMillan to participate, and he was engaged in the search thereafter.

3.                  Location of Mr Pudney

3.1.           Mr Ryan McMillan made a statement which was admitted as Exhibit C7d.  He said that he was employed at Arkaroola Village as a general assistant and assisted in the search for Mr Pudney on 15 January 2005.  He said that he rode his motorcycle around the tracks searching for Mr Pudney.  He stated that after some time he turned down the track which leads to Arkaroola Springs and on travelling that track he saw what he thought was a white shirt.  As he got closer he realised that this was a man lying on the side of the track.  He stopped his motorcycle and approached the man but did not touch him.  Mr McMillan said that he could see that the man was deceased.  Mr McMillan saw a backpack under a tree nearby.  Unable to obtain radio contact, Mr McMillan rode his motorcycle away from the scene with the object of getting help.

3.2.           By one means or another Mr McMillan made radio contact and eventually encountered Mr Sprigg and members of SA Police who were in a minibus driving towards the airstrip on the main road out of Arkaroola heading south.  They met at the junction near a place called Ochre Well.  Mr Sprigg said that Ryan McMillan was very shaken.  They alerted other members of the search team and proceeded to the site at which the body had been located.  Mr Sprigg attended with the police officers including Sergeant Harris.  Mr Sprigg had trouble recognising the person as Mr Pudney but realised that it must have been him.  In my opinion, the circumstantial evidence is such that it is quite clear that the deceased was Martin Pudney.

3.3.           Mr Sprigg said that they proceeded from the site at which Mr Pudney’s body was found to the place where his vehicle had been located earlier.  This involved proceeding, at least in part, in the reverse direction of travel as laid down for the Echo Camp Backtrack.  They had recovered some car keys from the body of Mr Pudney and these matched the Nissan X-Trail.  Mr Sprigg was able without any difficulty to reverse the vehicle.  A police four-wheel drive was then used to winch the vehicle up the slope in order that it could continue its journey on the flatter ground.  Mr Sprigg was of the opinion that the vehicle was in perfect working order and could probably have driven up the slope itself.  The reason why this was not undertaken was in order to preserve any evidence of mechanical malfunction that might have been obliterated in an attempt to drive the vehicle up the slope.  In the result, no mechanical fault could be found with the vehicle when it was examined by Christopher Graham, a qualified motor mechanic attached to the Major Crash Investigation Unit with SA Police[4].

3.4.           Mr Sprigg said that he observed some fine material in the track immediately ahead of the vehicle which Mr Sprigg believed had been placed there by Mr Pudney in an apparent attempt to facilitate the passage of the vehicle up the sloping track.  It was Mr Sprigg’s opinion that this material would not have assisted in that regard, and may in fact have hindered.  In any event, Mr Sprigg noted no particular signs of wheel spin beyond the minor indications which I have referred to earlier in this finding.  Certainly the vehicle was not bogged.  Furthermore, the clutch appeared to be in perfect working order.

3.5.           Within the vehicle, Mr Sprigg noted that there was water in the form of melted ice in the esky and a number of cans of drink in the rear of the vehicle.  Furthermore, there was the ten litre water container to which reference has previously been made which Mr Sprigg estimated to be two thirds full.  Mr Sprigg also noted that there were dry “nibble” type foods in the vehicle which did not need to be refrigerated.  Mr Sprigg drove the vehicle back to Arkaroola that night.

3.6.           Mr Sprigg said that it was his opinion that if Mr Pudney had stayed with his vehicle he would still be alive today and that this is the major lesson to be learnt from this tragic event.  Mr Sprigg was asked why he had not considered carrying out a search on the Friday night immediately after he had been informed of the abandoned vehicle by the German visitors.  He stated that most of the staff of Arkaroola were away at that time because it is the quiet summer season.  He said that there was only one other person apart from himself that he felt that he could trust for a search without endangering life.  He felt that there was no point in driving the track that night with a view to finding Mr Pudney because he was aware that the German tourists had already driven it.  He said that the Arkaroola Spring track, on which Mr Pudney was eventually found, was definitely not a track that Mr Sprigg would have considered searching at that early stage.  He said that there are 100 kilometres of tracks in Arkaroola and that when conducting a search and rescue, a process in which he has had some training, it is logical to proceed from the most likely to the least likely locations in that order.  Mr Sprigg was surprised that Mr Pudney was found on the Arkaroola Spring track and it was not, in his opinion, a likely direction of travel for Mr Pudney.  In my opinion, that was a reasonable assessment.  I make no criticism whatsoever of Mr Sprigg’s decision not to conduct his own search on the Friday night.  He was entirely within his rights to leave the matter where he did that evening, namely, in the hands of the police.

3.7.           Mr Sprigg said that since Mr Pudney’s death the management of Arkaroola has locked the access gates to the Echo Camp Backtrack.  A payment is required to procure keys to the gates, and the travellers must sign a document acknowledging that they have appropriate four-wheel driving expertise of an advanced nature in order to tackle the track.  They also undertake to provide advice of their safe return in order to avoid the instigation of searches.  These measures are, in my opinion, appropriate and reasonable.

4.                  Dr Allan Cala

4.1.           Dr Allan Cala gave evidence of his post mortem examination of the deceased.  Dr Cala put the time of death at a period of up to 36 hours prior to the discovery of Mr Pudney’s body.  Dr Cala’s opinion was that it was more likely that Mr Pudney died earlier in that period rather than later but conceded that he could not rule out the possibility that Mr Pudney may have been alive on the Friday night.  However, I think it unlikely that Mr Pudney was still alive on the Friday night.  Even if he had been alive at that time, he would have had to have been located within hours of the alert having been raised by the German tourists to have had any prospect of survival.  The fact of the matter was that it would not have been possible to have mounted a safe and adequate search and rescue operation at 9:30 pm on the Friday night that would have had any prospect of locating Mr Pudney.  Certainly any such operation would have been hazardous to those involved and I doubt whether it would be feasible to attempt such an exercise except in daylight hours.  For that reason, the earliest that a search could have been commenced would have been at first light on the Saturday morning.  It is true that the search was not commenced for some hours after that, but there is no doubt that Mr Pudney would have been deceased long before first light on Saturday, 15 January 2005 having regard to Dr Cala’s evidence.

4.2.           It follows that the absence of any response by police to Mr Sprigg’s telephone calls on the Friday night was not in any way a contributor to Mr Pudney’s tragic death.  That said, it is of course a matter of great concern that a report of the finding of an abandoned vehicle by a person of the standing of Mr Sprigg would be ignored by SA Police for a period of nearly half a day.  Presumably it would have continued to have been ignored had it not been for the fact that Mr Sprigg renewed his contact on the Saturday morning.  If proper action had been taken by SA Police on the Friday night, Mr Pudney’s remains might have been found hours earlier, because searches could have been commenced at first light.  Even in death he deserved the dignity of a speedy search.  Instead he was left to the elements, hours longer than necessary, with all that entailed for his distressed relatives.  The evidence before me revealed that the officer responsible for this oversight is no longer employed by SA Police and that SA Police responded appropriately in instigating disciplinary action against her.

5.                  Conclusion

5.1.           In my opinion there is no need for any recommendation to be made in this matter.  It would be useful however for the Department of Transport or some other appropriate organ of Government to remind the travelling public, and particularly those who might travel to remote areas such as Arkaroola, of the well established principle that one should never leave a vehicle if it should become stranded in some way and that it is much safer to remain with the vehicle and await rescue.  In the present case, Mr Pudney had ample water and food to sustain him at least until the arrival of the German tourists on the Friday afternoon.  Indeed, he probably had sufficient food and water to sustain him for a considerably longer period than that.  He also had ample fuel in the vehicle to be able to run the vehicle’s air conditioner and cool himself down periodically during the hottest part of the day.  It was undoubtedly a tragic mistake to leave the vehicle in the circumstances in which he did.  This is a tragic reminder of the wisdom of the principle of staying with a stranded vehicle when one is in a remote location and I trust that it will be reinforced by the appropriate organs of Government.