Tragic Death Resulting from Multiple Actions, Reveals Coroner's Report

In 2019, Coroner Meenal Duggal found that Tākaka woman Tracey Smith died from hypothermia while tramping in Nelson Lakes National Park. The investigation into her death, conducted by an independent Issue Specific Advisory Group consisting of the Department of Conservation (DOC), NZ Police, and Mountain Safety Council (MSC), analyzed Tracey's death and other tramping incidents, and proposed six solutions to improve safety.

The severe weather during Tracey's tramp included low temperatures, deep snow, and poor visibility. The MSC's report highlighted how seemingly small decisions can compound into a series of errors, each making the situation worse until they become fatal. One of the compounding factors in Tracey's death was the lack of quality food and rest, and the cotton clothing she wore on her legs.

Being prepared to make early and conservative decisions to stop and turn back, especially when encountering terrain and weather conditions beyond experience and fitness, is crucial. Allowing enough time to complete the trip in daylight hours and having alternative plans in case it takes longer or conditions change is also important.

The routes and tracks leading to Angelus Hut in Nelson Lakes National Park are identified as a hotspot for tramping incidents in Aotearoa with an incident rate of approximately 1 in 700 trampers requiring search and rescue (SAR) assistance between 2010-2019. The MSC's report noted the influence of two heuristic traps; social proof and scarcity, which may have affected Tracey's decision making.

In light of these findings, the MSC endorsed several recommendations to prevent future similar tragedies. These include being aware of the experience and fitness levels of all group members and anticipating how the terrain may change in different weather conditions. Not wearing cotton layers as they draw heat away from the body when wet is another important consideration.

The MSC offers free resources and information to support basic skills and knowledge, including trip planning, tramping/field skills, basic navigation, and river safety. Always carrying an emergency communications device when heading into the backcountry or outside of reliable cell phone coverage is also essential.

Learning to identify the signs of hypothermia and acting quickly to get warm again is vital. Acting on advice given by trusted sources such as DOC visitor centre staff is also advisable. Always carrying some form of emergency shelter on all tramping trips, even in summer, is another precaution that should be taken.

The group's report also identified critical decisions that contributed to Tracey's death, such as proceeding to Angelus Hut and not turning back once conditions became impassable. The Coroner endorsed that trampers who are in possession of an emergency communication device should not hesitate to activate it when a person's life is or may be at risk.

Two of the six proposed solutions have been completed, and the other four will lead to shared projects between MSC and DOC. The Plan My Walk app is a resource for both experienced and beginner trampers, allowing them to find the right track for their abilities, check for track alerts, weather warnings, and receive a suggested gear list.

The MSC also provides helpful videos to support trampers. Allowing enough time to take regular rest breaks to eat and hydrate, especially in cold and wet conditions, is important. Rebekah Wilson can be contacted for any other queries, data, or photos at rebekah.wilson@our website.

The header photo shows Angelus Hut in winter conditions, serving as a stark reminder of the harsh environment that trampers must navigate. The lessons learned from Tracey Smith's tragic incident serve as a call to action for all trampers to prioritize safety and make informed decisions to ensure a safe and enjoyable tramping experience.