Poor maintenance by Woolworths has been blamed for an elderly woman's death when a shopping trolley rolled back and pinned her under her husband.
Irmgard Polklaser, 76, suffered pelvic and spinal fractures and other internal injuries when she was crushed.
The heavily-laden trolley rolled backwards on a travelator and pushed the woman's husband back onto her as it crushed them both under its weight.
The accident happened at Tea Tree Plaza shopping centre in Adelaide in August 2010.
The inquest was told the husband struggled to control the trolley when its wheels failed to lock into the travelator as the couple ascended, and it tipped over onto them.
Security vision Security vision tendered to the court showing the trolley rolling back onto Mrs Polklaser's husband, who lost his footing and tumbled onto his wife with the trolley on top of him.
"It is quite clear that the left-hand braking device of the trolley used by the Polklasers had no padding on it at all," ruled Coroner Mark Johns.
"This is not a case of a worn braking pad.
There was no worn surface, the pad was missing altogether." The court heard the braking device on the right-hand rear wheel also was not operating correctly.
"I conclude that Mrs Polklaser's injuries were sustained as a direct result of the lack of a proper brake pad, or any brake pad on the left-hand rear wheel of the Polklasers' trolley.
But for the lack of a proper or any brake pad, the accident would not have happened," the coroner said.
The court also received CCTV footage of four other incidents at the same shopping centre in which customers had been injured in similar ways, prior to Mrs Polklaser's death.
Three of them involved Woolworths trolleys and the fourth involved another supermarket's trolley.
"Each of the incidents described above was serious.
In some cases the shopper was quite badly injured.
They show that Mrs Polklaser's tragic accident was not an isolated case," Mr Johns said.
The SA Coroner recommended a wide audit of incidents involving shopping centre travelators.
Closure Outside court the victim's husband, Walter Polklaser, said he hoped to find some closure from the tragic event.
"You have to move on, like it or not," he said.
"It's the best closure, hopefully the best closure I can get." Mr Polklaser said he hoped the maintenance concerns raised would serve as a wake-up call to supermarkets.
"That should be looked into in future times so those things, especially frail [people] accidents should never happen any more." The ABC contacted Woolworths and it issued a statement.
"The death of Irmgard Giesela Polklaser was a tragedy and Woolworths has extended its condolences to her family," it said.
"We are always looking at ways to improve our customers' shopping experience and the safe operation of our stores.
As part of our trolley improvement program, we have upgraded all the trolleys at Woolworths Tea Tree Plaza and Marion."