Finding into death of Cheryl May Currie
Deceased
Cheryl May Currie
Demographics
39y, female
Date of death
2009-06-12
Finding date
2015-08-28
Cause of death
smoke inhalation
AI-generated summary
Cheryl May Currie, 39, with complete paraplegia from a 1998 spinal cord injury, died from smoke inhalation in a bedroom fire on 12 June 2009. The fire was caused by smoking in bed. Investigation revealed critical systemic failures in her community care coordination and fire safety planning. Despite her complex disability and smoking behaviour, no fire safety risk assessment was conducted, no evacuation plan existed, and her wheelchair was placed 4 metres away, preventing escape. The Transport Accident Commission (TAC), which funded her care, was unaware she lived alone overnight. Carers received no fire safety training and smoke alarm testing was inadequate. The coroner found no individual clinical error by providers but identified significant systemic shortcomings in service coordination, risk assessment, and training. Extensive recommendations addressed fire safety assessment protocols, case management, mandatory fire safety training for care workers, and improved smoke alarm systems for vulnerable disability clients.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- imprudent use of smoking materials in bed whilst incapacitated
- complete paraplegia preventing evacuation
- wheelchair placed 4 metres from bed preventing access
- living alone overnight without emergency support
- lack of fire safety risk assessment and emergency planning
- inadequate smoke alarm maintenance and testing regimes
- personal emergency response system not linked to smoke alarms
- lack of fire safety training for carers
- gaps in service coordination and communication between providers
Coroner's recommendations
- Basic Home Fire Safety Training Materials to be mandated for all in-home disability care providers through inclusion in induction and skills maintenance programmes
- TAC to conduct individualised fire safety risk assessments for clients with complex high care needs, including photoelectric smoke alarms with 10-year batteries, interconnected alarms linked to personal emergency pendants, heavy-high sided ashtrays, flame retardant bedding where smoking in bed occurs, mobility aids left near bed at night, emergency evacuation planning, and consideration of sprinkler systems
- TAC to develop fire risk assessment policies and procedures incorporating fire safety into assessment processes, amending occupational therapist review forms to address fire risk, identifying high-risk clients, and ensuring service providers assist with smoke alarm testing
- TAC to review its service delivery model to give consideration to use of case managers for clients with complex high care needs
- TAC to include in service agreements with all brokered in-home service providers that workers must have undertaken Basic Home Fire Safety Training
- TAC to require all service providers to provide Basic Fire Safety Training to workers through amended service provider contracts
- DHS to include fire risk assessment as part of planning and building new homes for persons with impaired mobility
- DHS and TAC to collaboratively identify all TAC clients with paraplegia or quadriplegia in DHS accommodation and conduct individualised fire safety risk assessments, considering installation of additional smoke alarms, sprinkler systems, automated doors and monitored alarm systems linked to smoke alarms
- TAC and MFB to develop a protocol for ongoing collaboration with respect to fire safety for TAC clients
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