Coronial
QLDhome

JTN and AJN

Deceased

JTN and AJN

Demographics

unknown

Coroner

Hennessy

Date of death

2008-08-12

Finding date

2011-10-10

Cause of death

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.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

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

  1. 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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