Coronial
VIChome

Finding into death of Stephanie Rebernik

Deceased

Stephanie Rebernik

Demographics

69y, female

Date of death

2023-02-27

Finding date

2025-07-03

Cause of death

Effects of fire

AI-generated summary

Stephanie Rebernik, aged 69, died in a house fire in 2023. She had an acquired brain injury from 1980 with cognitive decline, poor risk identification, and a documented five-year history of unsafe fire-lighting behaviours and smoking in bed. One month before death, she had deliberately set fire to her bed. Her NDIS disability support provider, All in One Support Services, was aware of these dangerous behaviours but failed to implement adequate fire safety planning. Critical gaps included non-functional smoke alarms (batteries expired February 2022) and no documented fire safety risk assessment or mitigation strategies. The coroner found the support provider had not taken reasonable steps to ensure working smoke alarms or develop fire safety plans despite clear knowledge of risk. While the fire was likely caused by a discarded cigarette, better fire safety infrastructure and planning could have prevented death or enabled earlier escape.

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

Contributing factors

  • Acquired brain injury with cognitive decline and poor risk identification
  • History of fire-lighting behaviours over five years
  • Regular smoking in bed
  • Previous attempt to burn mattress one month prior to death
  • Significant mobility limitations requiring electric wheelchair
  • Non-functional smoke alarms with expired batteries
  • Inadequate fire safety planning by NDIS support provider
  • Lack of documented fire safety risk assessment
  • Support worker awareness of dangerous behaviours without mitigation
  • Medications causing drowsiness

Coroner's recommendations

  1. 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 (noting this recommendation was previously made in COR 2019 000309 and the Commission has now published a Fire Safety Measures Provider Alert in December 2024)
Full text

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —