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Coroner's Finding: KERRISON Noel James

Deceased

Noel James Kerrison

Demographics

82y, male

Date of death

2000-06-02

Finding date

2001-08-28

Cause of death

Carbon monoxide poisoning, contributing factor: ischaemic heart disease due to coronary atherosclerosis

AI-generated summary

An 82-year-old man died from carbon monoxide poisoning in his home. His gas cooker had a faulty regulator operating at 0.7 kPa instead of the required 1.0 kPa, causing excessive pressure drop when burners were activated. This malfunction likely caused a flashback producing carbon monoxide. The cooker lacked flame-failure safety devices on hotplate burners. Pre-existing ischaemic heart disease predisposed him to death at lower carbon monoxide saturation levels. The death was preventable through regular gas fitter inspections or installation of flame-failure safety devices costing approximately $150. Clinical lesson: awareness of environmental hazards affecting vulnerable elderly patients, particularly those using appliances for heating.

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

Contributing factors

  • Faulty or maladjusted gas cooker regulator operating at 0.7 kPa instead of 1.0 kPa
  • Excessive pressure drop to 0.2 kPa when all four burners activated
  • Lack of flame-failure safety cut-out device on hotplate burners
  • Likely flashback causing incomplete combustion and excessive carbon monoxide production
  • Pre-existing ischaemic heart disease predisposing to death at lower carboxyhaemoglobin saturation
  • Closed unit with no windows open
  • Possible use of cooker as heating device

Coroner's recommendations

  1. Issue public warning that gas cookers should be tested regularly by a qualified gas fitter
  2. Recommend fitting of flame-failure safety cut-out devices to gas cooker hotplate burners
  3. Warn users that using a gas cooker as a heating device is unsafe due to fire hazard and risk of carbon monoxide poisoning if the cooker is faulty
Full text

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