From the silent voice of death come the soundest lessons in life

The now deceased CEO of Diemould


“...the repercussions of putting a hole in the wrong place are not even worth mentioning.”


Diemould’s Apprentice Master


“(Daniel) was very paranoid about whether he was doing something right or wrong – took him longer than others to gain self confidence – he asked trivial questions.”


EEAGTS Apprentice Supervisor


When asked about concerns that Daniel may have had: “At that particular point, Daniel did make me aware, look, his discomfort was nothing more than a desire to learn more about the job as such.”


Diemould’s Operations Manager


His opinion on the level of safety of the Horizontal Borer in July 2010: ‘My opinion of the machine is that it’s a large machine and we know the spindle turns and I think if the machine is used as its intended to be used...”


An Independent Risk Consultant


“This machine needed to be guarded and that’s (death) the outcome” ... Because it’s too risky not to guard.”


The now deceased CEO of Diemould


“Yes, it’s the best training we had for the apprentices because they couldn’t make a mistake...”


An Apprentice Employed By Diemould


 “When we started we were issued dustcoats like everyone else ..”

This puts the evidence of DAVID McMINN into question as he maintained that apprentices were not issued dustoats.


Senior Staff - Apprentice Management


“I went to about 4 machine shops and I recall seeing at least two that had borers the same size as what Diemould had and being operated in the same manner as Diemould did and if fact there’s even – there’s workshops in our local area that are still running those size machines and even a bigger machine.  I know of a bigger machine that’s in the Edwardstown area that’s being operated in a similar fashion.” P853 L18 TRANSCRIPT

This evidence was relayed to Brian Russell (SafeWork SA) with requests to follow up on these Horizontal Borers.


1st Year Apprentice


“There wasn’t a lot of supervision on overtime.  I only worked one Saturday but I turned up at 6.00am and there was only Daniel Madeley in the Eastern Workshop and one other person in the Western workshop.  Daniel was already working when I got there and he’d been there for about an hour working alone.”


1st Year Apprentice


“In the graphite room we worked alone as well with Paul in the block up area and the door closed to prevent graphite getting everywhere.”

MAY - JULY 2010

Report Uploaded: Wednesday, June 22, 2011


I was caught by surprise when I learned in March 2010 that there would be an inquest into the Daniel’s death.  I wasn’t complaining that an inquest was coming, it’s just that it came as such a shock and I thought I’d sat in my last court room listening to lawyers talk about my beautiful Danny and that awful day. The Industrial Courts had been dealing with this matter for 5 years and it all seemed like at that point, once a penalty was handed down, that this was the end of the matter.

A few weeks later I contacted Nick Xenophon.  I was a little unsure about a question I was asked in terms of wanting to be ‘represented’ at the inquest.  I didn’t quite understand why I would need to be - on account of that I hardly needed to defend myself did I?  I mean, in my mind, only someone who needed a lawyer needed a lawyer...if that makes sense?

Nick explained to me that if I was represented, I could have questions asked on my behalf - questions that I felt were important. that was something I very much did want.

At this point I think I must have asked if I could represent myself since I knew I could not afford a lawyer and with time so fast running out, a decision needed to be made. I made a call to the Coroner’s Court asking whether I would be allowed to represent myself but I got the impression it wasn’t something they were thrilled about.  They suggested the Coroner’s Counsel could ask all the questions I needed asked but...I don’t know, it seemed like for so many years I sat by and watched these proceedings go by while I sat there screaming inside for a voice.  No, this time I wanted a voice.  This time, I do believe it was my legal right.  My gut told me this was exactly the right thing to do.

Unfortunately I didn’t realise that I could have had copies of the brief to study prior to the inquest starting.  What I should have been doing was studying all those statements and going through them with a fine tooth comb before I ever stepped foot in that court room.  I did have a list of questions prepared but it soon became evident to me that without knowing what was in all those statements, I wasn’t even close to the mark on having the right questions on day 1.

Nick’s Xenophon and John Darley’s office were on hand to assist in getting at least those documents from the witnesses that were first called up.  I think if there was a blood pressure monitor on me at that point, it may well have flung off my arms.  Every spare second was spent reading statements and transcripts from the day before - all the while I was trying desperately to disassociate myself with the fact that all this was about my son and that God awful machine.  

There were a hundred times I had wished I could just crawl into a hole and let the earth swallow me up.  I was hearing and reading things for the first time that were gut wrenching and heart breaking.  I was seeing images for the first time that were shocking for anyone to see, let alone a Mother.  As the voices in my head would get louder, my resolve got stronger.  There would be a time for me to shut down for a while but right now wasn’t that time.  I thought constantly about what Daniel went through that day.  I reasoned with myself, “This isn’t that difficult Andrea.  What he endured was mind boggling - frightening - this is a walk in the park compared with what he went through ... “ And so that kept it all in perspective.      


I learned that I had been unbelievably naive and that was the hardest lesson of all.  

I certainly didn’t expect all that much from the management of the company because I’d already come to terms with the fact that they were prepared to sink a lot of money into a technical issue that would eat away 5 years, but I never expected to hear the inconsistencies (even downright untruths) from so many of Danny’s apprentice workmates.  

There was initially no legal representation for Diemould Tooling when the inquest began.  That all changed rather quickly when things began to get, well for want of a better word, untidy.

A couple of days into this inquest, it became evident something wasn’t adding up. There were these so called ‘notes’ that were being referred to by several witnesses.  These notes appeared to be something to help them remember.  Isn’t it odd that those witnesses referred to them as ‘their notes’?  I suppose where it came unstuck was the Coroner was at a vantage position to read some of the text as the witnesses referred to these ‘notes’.  It then became evident that what they were referencing were in fact a statement of legal privilege taken by the companies lawyer, Rosie Batt. That seemed a stark contrast to the idea they were reading from ‘notes that they made’.

What came to light as the issue of ‘notes’ became a focus was that this ‘meeting’ or as I like to refer to it, a neat gathering of summonsed witnesses at Diemould a few weeks prior to the Inquest starting. Only after some rigid questioning by the Coroner did this information come to light.  

The evidence from initial witnesses (prior any knowledge of this gathering of witnesses) who attended this meeting seemed to struggle to recall who the lawyer was that interviewed them and took these statements, err sorry ‘notes’ that they had brought along.  Gosh, they’d sat in a board room with her  just a couple of weeks beforehand!

Evidently people were worried when they received their summons to give evidence in the Coroner’s Court. Apparently they couldn’t understand why they were being asked to relive this nightmare.  After all, they had been put through so much already! They were trying to forget. (Ho bloody hum...)

They wanted to forget...?  Gosh - I was dumbstruck by these people.

It was said Rosie Batt advised that it was unusual for an inquest to happen.  I wondered whether her professional opinion may have put some concerns on the table that night?  We heard that management were extremely agitated...and why was that the case?  I couldn’t help but feel sceptical.  What on earth were they so worried about?

I can honestly say, of all the upheaval that had ravaged my life since I lost my son, I had not known such bitterness.  I wanted to bull whip each and every one of them. How dare they treat the death of my precious son with so much contempt.  

It was perhaps something I had not prepared myself for. That the people that Daniel had called his ‘mates’ at work were now displaying the shallowest form of mate ship that I had ever seen.  He was long forgotten. They didn’t care about anything but themselves and protecting each other.  

There were suggestions that Daniel must have been doing something wrong - that he must have made a mistake.  All these years later, with a prosecution under belt, too many of these morons still believed that machine was essentially safe - unbelievable!

I found it near impossible to reconcile the evidence relating to some of the witnesses that attended that meeting.  Some evidence was so riddled with contradictions – too much was subject to convenient memory loss and some was just downright mysterious.

I feel for Lynette Oaten - the then Workplace Services (SafeWork SA) inspector in charge of investigating Daniel’s death.  

She had been made out to be – well yes, I do believe the words used by the late Neville Grose had his opinion of her – an ‘aggressive bitch’.  What these self-interested cretins do not seem to comprehend is that she was investigating the death of one of their work mates! She had a job to do and I sense from the evidence that it was made as difficult as possible for her.

Lynette Oaten walked away from her career after this investigation.  She was, I believe someone that did that job with a passion and for that she has been crucified.  Shame on them and shame on a system that allowed Diemould Tooling to mess with this important investigation process.

Unfortunately many of the apprentices were quite young at the time and I suspect were easily influenced by the management.  I probably should make allowances for that – but I was gutted by what I heard. We all have choices in how we behave.  Their decision was to stick it to their dead workmate and stand by their boss - lie if need be.

I’m so grateful that we had a couple of apprentices appear in court that were not a part of this meeting and so it was their evidence that made the rest look contrived. If DANIEL GOLDFINCH and CHRISTINE STOCK were having trouble recalling something that happened years ago, it was credible. There wasn’t a host of time spent on ‘notes’ or other statements. These 2 apprentices (at the time) answered quickly and honestly. They can hold their heads up high. These two young people are what workmates are all about.  No axes to grind, no need to cover anything - just tell the truth and see this doesn’t happen to some other unsuspecting worker.

There was no doubt in my mind that the late NEVILLE GROSE was an egotistical man.  In his statement to Lyn Oaten (Workplace Services Inspector) he comments about all the changes that Diemould had made since the death - and he states quite clearly, “...we don’t ever have this problem again”. C18aaaaas P69 L7 and 12

What an insult and yet no great surprise to me by now - to paraphrase such a tragic event as a problem.

Equally I did not feel that the attitudes of the current management had changed that much in 6 years.  One only needs to reference the thousand odd pages of transcript to see how they (still to this day) couldn’t grasp that Diemould Tooling had done much wrong.

JIM GROSE with that prompted apology.  I didn’t buy it - it would have meant something had it not come after 6 years of court rooms.  Sorry but JIM GROSE and RUSSEL DANIEL were the driving force behind that - no point blaming the late NEVILLE GROSE - no point apologising.

A company is not unlike a vehicle - and it is controlled by people.  The decisions are made by people.

I recall quite clearly how Diemould Tooling was experiencing some financial hardship during their Plea Submissions in the Industrial Courts less than 12 months prior to this inquest.  There was a lot said about the terrible financial situation of the company at that time - no doubt in order to ensure as lenient a fine as possible.

Now we learn (during this inquest) that JIM  GROSE has managed to invest in and add another tooling venture to his list of companies.  Isn’t it so warming to see how easily a company manages to pull itself out of financial trouble at break neck speed as soon as it’s done pleading ‘poor’ to the Industrial Magistrate.

 I just can’t help but wonder, what is there to stop a business from simply moving its operation to another facility - leaving it with a clean slate and no baggage?  Those that caused the Gladstone explosion did just that in the NT.  Easy isn’t it?  


I look back at that Inquest today and I know it was the single most valuable event that occurred in relation to my son’s death.  I experienced first hand the difference between the Industrial Courts and the Coroner’s Court - and there are significant differences.  This is the court that has some hope of uncovering things that are so easily hidden through the criminal justice system.  When your primary witness is dead, this court hears what many other courts cannot.

I would however add that attempting to represent oneself at the bar is not something I would advocate.  There is no question in my mind that families should be represented at the bar in their own right, but I believe it’s a massive burden to place on a family member.  I look back at the pressure I felt - because at a personal level, the stakes were astronomically high.  Each and every time I made a mistake or lost my train of thought while I was asking questions (and that happened a lot because I was having trouble coping with the process) I recall quite clearly this enormous sense of guilt that I was letting Danny down.  Daniel deserved someone professional and passionate to represent his family.  It’s painfully clear to me that this is something VOID should be able to offer.  It should not be born by the family to fund such things.  

That said, I am glad that I tried - no regrets. I remember ringing a couple of lawyer friends several days before closing arguments.  I needed some advise - what do I need to do - what would I be expected to deliver?  One of these friends said, “No one would really expect you to do too much here’re his mother not a lawyer - this is the job of the Coroner’s Counsel”. Okay so this advise did reduce my anxiety a little. It’s true - I am not a idea what I am supposed to deliver.

I must admit though, some hours later I felt uneasy about all that.  I made another call.  He said, “Well Andrea, people would certainly understand if you put together a fairly brief ‘closing’, but ...’ And I do believe I cringed when I heard the ‘but’, “My advise to you is to be very thorough, make your argument easy to follow and take as long as you need to raise your points. In other words, leave no stone unturned...”  

There it was - the gauntlet.  I do believe there was a friendly challenge in all of that.  Bloody hell, I had just spent Mother’s Day 2010 looking at Daniel’s clothes and blood covering this awful machine! That was damned hard.  Listening to Daniel’s workmates lie?  That was heart breaking.  Yes I was exhausted and really just wanted to curl up in bed for the next 6 months but ... Not yet.  The time for rest will come after this is over.

I won’t soon forget the lead up to the date of closing arguments.  I had worked on this file for a solid week but as the date drew closer, I was feeling more and more overwhelmed.  There was so much to cover - so many things that I didn’t want to let slide.  The final run down came down to a 36 hour straight stint in from of the computer trying to mesh together all the files I had created into something that made sense - that flowed.

I didn’t mean to work through the night but somehow I just wasn’t able to get it finished. Sam got up for work at 4.30am, made me a big strong coffee and an egg and bacon muffin.  He was not happy - well, he was worried knowing I had a long drive into the city yet to come.  He rang me several times checking to make sure I was okay.  There’s no question, the fatigue had set in and I was on the brink of tears the whole way.  Mostly I was scared - scared of letting my Danny down -  scared of not delivering enough - not doing enough.  God I was running on pure adrenalin by this point.  Not one ounce of energy left in reserve.

Look, it’s just not something I think family members should be expected to go through in order to find a small slice of justice.  The truth is our courts are flooded with cases and those trying to argue these matters do this knowing that tomorrow there will be another file to look at.  There has to be a better way.