Finding into death of Carol Fay Slade

Contributing factors

• Careless or improperly extinguished cigarette ignition source
• Reduced mobility requiring walking frame
• Impaired judgment due to prescription and illicit drug use (methadone, diazepam, tapentadol, methylamphetamine, ketamine)
• Alcohol intoxication
• Acquired brain injury affecting awareness and cognitive function
• Security screens on windows impeding emergency exit
• High smoke and toxic gas exposure preventing escape
• Smoking behaviour while affected by substances
• Lack of bedroom smoke alarm
• Non-interconnected smoke alarm system

Coroner's recommendations

1. Victorian Government to consult with Fire Rescue Victoria and Country Fire Authority to introduce improvements to smoke alarm requirements within Victorian Building Regulations
2. Victorian Government to consult with Fire Rescue Victoria and Country Fire Authority to introduce an auditable regulatory compliance inspection process for domestic smoke alarms as part of residential property sales
3. Victorian Building Authority to publish guidance clarifying who can design, install and certify home fire sprinklers to the FPAA101D specification
4. Department of Energy, Environment and Climate Action to work with Victorian water authorities to develop policies streamlining approval process for cost-effective installation of water meters meeting pressure and flow requirements for home fire sprinklers
5. Department of Transport and Planning and Australian Building Codes Board to conduct research into adopting home fire sprinklers to FPAA101D specification within National Construction Code where not currently required
6. Australian Government Department of Health, Disability and Ageing to consider whether warnings about fire and burn risk should be included on mandatory health warnings on cigarette packaging