Finding into death of D VR
Deceased
DVR
Demographics
3y, male
Date of death
2020-08-15
Finding date
2022-11-30
Cause of death
Smoke inhalation
AI-generated summary
A 3-year-old boy died from smoke inhalation after a fire in his mother's public housing apartment. The fire likely originated when the child transferred a lit object from the stove to a couch. The mother attempted to use a fire hose to extinguish the fire but was unable to deploy it due to maintenance deficiencies—the hose was tangled and the nozzle valve was non-functional, despite recent servicing. Autopsy confirmed smoke inhalation with carboxyhaemoglobin at 40% and hydrogen cyanide. The coroner found no one accountable for the child's death but identified systemic failures: inadequate fire hose maintenance despite AS 1851 compliance records, lack of fire sprinkler systems in public housing, and absence of fire safety education targeting vulnerable families with young children. Key preventive recommendations include installing sprinklers in all public housing, enforcing technician licensing for fire system servicing, and integrating fire safety education into maternal and child health nursing services.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Fire originating from child transferring lit object from stove to couch
- Presence of lighters and cigarettes accessible to child in apartment
- Fire hose maintenance deficiency—hose tangled and nozzle valve non-functional
- Absence of fire sprinkler systems in public housing
- Lack of fire safety education for parents in socioeconomically disadvantaged communities
- Child aged 0-4 years at highest risk group for fire-related fatalities
Coroner's recommendations
- Department of Families, Fairness, and Housing (DFFH) to consult with relevant organisations and conduct a feasibility study into installation of fire sprinkler systems in all current and future public housing premises
- DFFH to ensure that all technicians performing inspections and testing of fire systems and other essential safety measures work hold appropriate licences to ensure servicing is performed to the requisite standard
- DFFH to consider the potential role of Maternal and Child Health Nurse (MCHN) services or other services in identifying and improving fire safety practices of parents of young children, particularly those facing social and financial disadvantage
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