Finding into death of Vivianne May Rodger
Deceased
Vivianne May Rodger
Demographics
54y, female
Date of death
2019-01-17
Finding date
2023-12-18
Cause of death
Effects of fire in a woman with past right middle cerebral artery territory stroke and pulmonary emphysema
AI-generated summary
A 54-year-old woman with left-sided paralysis from a prior stroke died in a house fire started by smoking in bed. She called emergency services at 2:42am reporting her blanket was on fire, but firefighters attended the wrong address (38A instead of 36 Maybury Drive) at 3:31am, found no fire, classified it as a malicious false alarm, and left. The actual fire became apparent at 4:59am when visible flames emerged; she was found deceased at 5:17am. Critical failures included: emergency dispatcher not adequately communicating her disability status to firefighters; firefighters spending only 4 minutes on scene without properly verifying the correct address despite visible house numbers; and absence of hardwired smoke alarms connected to her personal alarm system. While early address confusion was understandable given incomplete initial information, the second attendance failure was preventable. Hardwired smoke alarms linked to monitored personal alarms would have significantly improved chances of timely emergency response for this non-ambulant disabled woman.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Firefighters attended incorrect address (38A instead of 36) following second fire call
- Inadequate scene investigation with total time on scene less than 4 minutes without properly verifying address
- Failure of firefighters to confirm property number or ask resident to direct them to correct address
- Communication from ESTA dispatcher to firefighters regarding previous false alarm likely influenced response
- Incomplete information from ESTA to firefighters not including caller's disability status
- Absence of hardwired smoke alarms connected to monitored personal alarm system
- Reliance on Melways paper map rather than GPS navigation
- History of smoking in bed, falling asleep while smoking
- Lack of formal MFB policies requiring address verification or callback to caller when no obvious fire signs
- Complex street numbering in area leading to address confusion
Coroner's recommendations
- That the National Disability Insurance Scheme Quality and Safeguards Commission ensure that training and information provided to NDIS service coordinators and providers includes information regarding the importance of ensuring appropriate fire safety measures are put in place for clients, including hardwired smoke alarms connected to monitored personal alarm devices
- That Fire Rescue Victoria implement appropriate policies, procedures and training to ensure that firefighters responding to a firecall, where the signs of a fire are not apparent, take appropriate and sufficient steps to identify the correct location associated with the firecall, and that these steps are confirmed with the Fire Rescue Victoria communication centre
Full text
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