Incineration from a house fire. The children were subject to poor supervision from their grandmother, had access to cigarette lighters, with the fire initiated in a bedroom with combustible materials. The house was unkempt with abundant fuel. Rescue attempts were hampered by lack of coordination and opening a window which provided oxygen to the fire.
AI-generated summary
Two young children (aged 3 and 2 years) perished in a house fire in 2008 while under the supervision of their grandmother, who had been previously determined by the Department of Child Safety to be inappropriate for this role. The children had easy access to cigarette lighters. Supervision was inadequate on the day of the fire—the grandmother left the children unattended for 10 minutes. The house was cluttered and messy, providing fuel that aided fire spread. During rescue attempts, a window was opened which increased oxygen to the fire. Whilst the Department had previously provided support in 2004 and Queensland Health engaged with the mother via an early intervention social worker in 2007, no concerns were reported to the Department between October 2004 and the fire. The coroner found inadequate supervision and concerning home conditions warranted departmental action, but these were not reported by family members or healthcare providers until after the tragedy occurred.
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Specialties
paediatricspsychiatrygeneral practicepublic health
Error types
systemdelaycommunication
Contributing factors
inadequate supervision of children by grandmother for approximately 10 minutes
grandmother previously determined by Department of Child Safety to be inappropriate person for supervision
easy access to cigarette lighters for young children
cluttered, messy house with clothing and household items providing fuel
lack of coordination between family members during rescue attempts
window opened during fire response, providing oxygen to fire
focus on fire extinguishing rather than child rescue
smoke alarm not operational at time of fire
no reportable concerns communicated to Department of Child Safety between 2004 and fire
no formal written referral to Rockhampton early intervention social worker after family relocated
Coroner's recommendations
No formal recommendations were made. The coroner stated 'In the circumstances of this matter I do not propose to make any recommendations or further comment.'
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