Finding into death of Christopher Alan Giorgi

Contributing factors

• Faulty electrical wiring and light fitting in restaurant ceiling above bedroom 3
• Absence of functioning hardwired smoke alarms despite Building Code requirement for Class 3 boarding house
• Inadequate fire separation between ground floor restaurant and first floor bedroom
• Unsafe deadbolt door locks preventing emergency evacuation
• Unregistered boarding house operating with more than five tenants in breach of Health Act regulations
• Building owner's failure to address known electrical defects and fire safety issues
• Boarding house operators deliberately providing false occupancy information to Council
• Council's failure to enforce fire safety compliance and inspect premises to verify undertakings
• Compartmentalized Council departments failing to coordinate oversight
• Termination of electrical maintenance at Pizza Hut restaurant
• Absence of sprinkler system or fire suppression equipment

Coroner's recommendations

1. Consumer Affairs Victoria to lead administration of Health Act Prescribed Accommodation Regulations and rooming house safety
2. Campaign to identify unregistered rooming houses and ensure awareness of fire safety obligations under Building Code
3. Consultative process involving Tenants Union, Council to Homeless Persons, Councils, Real Estate Institute, and MFB to identify unregistered low-cost boarding houses
4. Grant Consumer Affairs search and entry powers with support from Council and MFB to ensure compliance with fire safety and Building Code provisions
5. Implement licensing system for rooming house operators with nominees as persons in charge, subject to fit and proper person criteria
6. Amend Health Act Prescribed Accommodation Regulations to require operators to prepare and publish emergency management plans
7. Amend Prescribed Accommodation Regulations to apply to all residential premises where more than one room is offered for lease or more than two persons normally reside in a room
8. Require boarding house operators to provide certificates from building surveyors confirming Building Code compliance, updated every three years
9. Amend Prescribed Accommodation Regulations to adopt Building Code fire safety provisions for all prescribed accommodation
10. Amend Health Act to impose more substantial penalties for non-compliance
11. Substantially increase maximum penalties in Building Regulations 2006 Regulation 1011 for change of use breaches
12. Support Municipal Council closure of premises and criminal prosecutions for serious violations
13. Amend Residential Tenancies Act to set out obligations of rooming house owners and operators under Building, Health and Planning legislation
14. Mandate prescribed form of lease agreement for rooming house operations setting out rights and duties
15. Mandate prescribed form of agreement for sub-lease of individual rooms to tenants
16. Real Estate Institute recommend members use prescribed lease forms for boarding houses or commercial agreements with defined duties
17. Real Estate Institute members notify Consumer Affairs Victoria within 7 days of all rooming house lease agreements and exclusions of subletting
18. Residents notify Consumer Affairs Victoria of existing pro forma residential tenancy agreements that exclude subletting provisions
19. Government of Victoria seek longer-term administrative arrangements to improve legislative compliance and efficiency of approvals system
20. Municipal Councils review internal communication systems to ensure Building, Health and Planning departments coordinate and share information
21. Provide adequate direction to Council staff through Director and Interdepartmental Committee on Rooming Houses to ensure cross-discipline enquiries comply with legal requirements
22. Amend Building Code Part D2 to exclude doors serving sole or double occupancy rooms in Class 3 boarding houses from exemption regarding locking mechanisms
23. Amend Building Code to require single locking device on each boarding house unit operated by external key and internal lever that cannot be locked from inside