Finding into death of Nigel Raymond Willoughby

Contributing factors

• Carelessly discarded or dropped cigarette butt as ignition source
• Unsafe smoking practices - smoking in armchair while drinking
• Alcohol consumption increasing fire risk
• Severe hoarding and squalor (CIRS level 6) blocking exit routes and increasing fuel load
• Deadlocked front door with no key preventing escape
• Blocked rear exit due to clutter
• Smoke alarm not serviced since 2009 (though operational at time of fire)
• Wall heater operation may have assisted fire spread
• Advanced age (74 years) affecting mobility and escape ability

Coroner's recommendations

1. Department of Families, Fairness and Housing should consider reconvening the Hoarding and Squalor Taskforce to promote best practice and inter-agency responses to hoarding and squalor
2. Department of Families, Fairness and Housing should update and reissue the 2013 publication 'Hoarding and squalor: a practical resource for service providers' or compile a similar publication
3. Victorian Government should consult with Fire Rescue Victoria and Country Fire Authority to introduce improvements to smoke alarm requirements within the Victorian Building Regulations
4. Victorian Government should 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 sale
5. Victorian Building Authority should publish guidance to clarify who can design, install and certify home fire sprinklers to FPAA101D specification
6. Department of Energy, Environment and Climate Action should work with Victorian water authorities to develop policies streamlining approval for water meters meeting pressure and flow requirements for home fire sprinklers
7. Department of Transport and Planning and Australian Building Codes Board should conduct research into adopting home fire sprinklers to FPAA101D specification within National Construction Code where not currently required
8. Australian Government Department of Health, Disability and Ageing should consider whether warnings about fire/burns risk should be included in mandatory health warnings on cigarette packaging