Inquest into the death of John FLAMISH
Deceased
John Flamish
Demographics
65y, male
Date of death
2017-06-05
Finding date
2020-12-11
Cause of death
combined effects of smoke inhalation, burns and ischaemic heart disease
AI-generated summary
John Flamish, 65, died on 5 June 2017 from smoke inhalation, burns and ischaemic heart disease following a deliberately lit fire in the carpark of public housing at 22-24 Early Street, Parramatta. The fire was set in a parked Mercedes belonging to resident Sidholm Nakhla. A significant contributing factor was that the fire door separating the carpark from the residential stairwell was propped open with a brick, allowing smoke to ventilate into the building. This practice had been ongoing for years prior to the fire. The coroner found smoke entered the stairwell, trapped residents upstairs including Ms Ludkin and Mr Toufan who had to be evacuated by ladder. The specific actions that could have prevented this tragedy include: proper closure and monitoring of the fire door, resident education about fire safety, and agency oversight of fire safety measures in public housing. While the person(s) responsible for the arson remain unknown despite extensive police investigation, the preventability centres on the maintenance of critical fire safety infrastructure.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- fire door propped open with brick allowing smoke to ventilate into residential stairwell
- practice of propping fire doors open was ongoing at the unit complex
- lack of fire sprinklers in carpark
- inadequate supervision and enforcement of fire safety measures by housing authorities
- deceased's vulnerability to smoke inhalation due to ischaemic heart disease and prior bypass grafts
- poor visibility in smoke-filled carpark and stairwell
Coroner's recommendations
- Commissioner of Police to consider making a reward for information regarding the fire
Full text
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