A father who drove the wrong way onto the Wellington motorway, killing both himself and his son, had dementia and was banned from driving, a coroner report reveals.
Lisale Foaese, 76, and George Foaese, 41, died in January 2021 after their car collided head-on with another on Wellington's Urban Motorway.
Coroner Heidi Wrigley has found the deaths were avoidable, and she suggests improving safety measures such as electronic signage.
Lisale entered the motorway on State Highway 2 near Petone and drove for about 13 kilometres before crashing close to Wellington city.
Multiple witnesses driving in the area beeped and tried to signal for Lisale to stop, and police received a number of calls.
The coroner said the driver appeared to be unaware he was driving on the wrong side of the road.
Coroner Wrigley wrote in her findings released this week that Lisale had just two weeks before the crash had his license suspended by police due to memory loss.
"It is axiomatic that compliance with the prohibition would have saved both his life and that of George."
The man's wife and mother of his children had died four months earlier, as well as another son not long after. Lisale's dementia was made worse by his intense state of grief, the coroner wrote.
The driver was also deaf and was not wearing his hearing aid on the night of the smash.
One witness described the collision like "two trains colliding on a train track", the coroner reported.
The two occupants of the other car involved lived, however, reports at the time said they broke several bones and underwent surgeries.
Days before the crash, Lisale was given notice that his license was to be posted to NZTA, and was advised that it was an offence not to return it.
His driver license card was found at the scene of the collision.
The report described Lisale driving oddly before the crash - almost hitting the median barrier, slowing down to almost a stop on the motorway, and speeding up to 105 km/h with the brakes lights on while not appearing to slow down.
The driver of the other car, which was a Holden, only had seconds to react. Tyre marks indicated the other driver braked before the collision, however, no evidence of this was found for Lisale's car.
George Foaese's mental health was found to have played a part in his death. The coroner said it impaired him from addressing the "very unsafe situation of being driven about by his father at night".
The case could serve as a warning to other families managing the cognitive decline of family members, the coroner said.
"Lessons can still be learnt from this case about what could go wrong when those responsible for supporting people with disabling mental health conditions are not well positioned to do so."
The findings would be given to Health New Zealand to inform practice and services, particularly in relation to needs and risk of those with debilitating mental health conditions.
Wrong-way driving solutions
The coroner and the Police crash investigator recommend that the Transport Agency consider installing electronic signboards over roads where wrong-way driving was difficult to stop - like motorways.
The signboards could be programmed to warn and instruct drivers when someone is heading toward towards them from the wrong way.
To guard motorists from entering SH2 from Cornish Street in Lower Hutt, where Lisale entered, signage at the time included two "No Entry" and two "Wrong Way" signs on both sides of the road, and a large notice stating "SH2 Access via Pito-One Rd, U-Turn required".
Lisale had limited English and may not have been able to read the signage.
The coroner argued that an electronic warning sign would have helped the other car involved in the crash.
"Such signage can empower oncoming motorists to take action to avoid entirely unpredictable and extremely highrisk collisions which may otherwise be difficult or impossible to prevent."
In the coroner's report, NZTA said it is looking for low-cost, automated solutions, like vehicle activated electronic warning signs.
The agency said it anticipated more advanced electronic signage safety measures will be introduced to Wellington "in the future".
