Tewantin House Fire - Non-inquest findings

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QUEENSLAND COURTS

OFFICE OF THE STATE CORONER FINDINGS OF INVESTIGATION

CITATION:

TITLE OF COURT: JURISDICTION: DATE:

FILE NO(s):

FINDINGS OF:

CATCHWORDS:

Non-inquest findings into the death of Rachel Naomi Hannah MacCRACKEN, Sage GOLINSKI, Willow GOLINSKI and Starlia

GOLINSKI

Coroner's Court

Brisbane

23 November 2015

2011/4380, 2011/4387, 2011/4385 & 2011/4388

Terry Ryan, State Coroner

CORONERS: House fire, multiple deaths, smoke alarms, ionisation type smoke alarms, photoelectric alarms

Table of Contents

Background

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Other inquiries Conclusions

Findings required by s. 45

Background

In September 2004, Matt Golinski and Rachael MacCracken married after having been in a relationship for many years. They had three children, Sage and Willow Golinski (who were twins aged 12), and Starlia Golinski (aged 10). They were described as a close and loving family. Matt and Rachael were focussed on caring for their children, two of whom had special needs.

The family lived together in a lowset timber home at 11 Jacaranda Place, Tewantin. The home was accessed via an easement and was approximately 120 square metres in total.

It comprised of three bedrooms, an open plan living and kitchen area, a front verandah and a rear deck. It was constructed in 1995 with a pine frame on steel posts, and was clad with particle board.

At around 3:30am on 26 December 2011, the Queensland Fire and Emergency Service (QFES), Queensland Police Service (QPS) and Queensland Ambulance Service (QAS) received numerous ‘000’ cails to attend a house fire at Jacaranda Place, Tewantin.

By the time the QFES arrived at 3:41am, the house was consumed by flames and could not be entered safely. Matt was at the front of the home and had clearly suffered major burns to his body. Matt was being consoled by neighbours, who reported that he had made repeated attempts to enter the house to locate his wife and three daughters who were all trapped inside the dwelling.

The fire was brought under control approximately one hour after the arrival of the QFES.

The remains of Rachael and her three daughters were subsequently located inside the house. Rachael's body was found in the twins’ bedroom, the twins were in the hallway and Starlia was in her bedroom.

Police investigation

An investigation into the circumstances leading to the deaths was conducted by Detective Senior Constable Ross Hutton from the QPS Sunshine Coast Criminal Investigation Branch.

The investigation was informed by statements and recorded interviews with: ¢ All police officers involved;

All emergency services officers involved;

Fire investigators;

A large number of direct and surrounding neighbours; and

A large number of next-of-kin and friends of the family.

Forensic analysis was conducted and photographs were taken. In April 2014, all of the evidence was produced to me in a report, which | have had regard to in reaching my findings.

1 am satisfied that the investigation was thoroughly and professionally conducted and that all relevant material was accessed.

Inspector Ronald Dorman from the QFES Fire Investigation Unit compiled a report in relation to the fire, which was provided with the police report. The QFES Report concluded that the fire started at or near a Christmas tree located in the living area and spread from this location. Observations of burn patterns on the surrounding floor structure, wall studs and furniture indicated that the fire started at this location.

Findings of investigation into the deaths of Rachel MacCracken, Starlia Golinski, Sage Golinski and Willow Golinski, 1

. The QPS Fire Examination Unit also attended the scene of the fire. Sergeant Darren

Smith led that examination, which revealed that there was no evidence of storage of chemicals prone to spontaneous combustion and the weather conditions were fine at the time of the fire.

. Sergeant Smith obtained assistance from an Electrical Safety Officer, Allan Dall, who was

unable to eliminate electrical involvement in the fire due to the extent of the damage.

Sergeant Smith also concluded that the fire originated in the area located around the lounge room, in the centre of the dwelling. He aiso provided opinion that the cause of the fire was undetermined, in that he was unable to eliminate human or electrical involvement.

. Detective Sergeant Garth Price from the Arson Investigation Unit also attended the scene.

Detective Sergeant Price examined the points of entry to the residence. He concluded that there was no evidence of any external forced entry to the dwelling. However, given the extent of the damage this was not a conclusive opinion.

. Detective Senior Constable Hutton interviewed Matt Golinski. Understandably, this

interview took place some months after the incident, in April 2012. As the sole survivor of the fire, Matt’s version of events was crucial to the investigation. Given the medical treatment required in the aftermath and the obvious trauma suffered, Matt had a reasonable recollection of the lead up to the fire.

Matt recalled that Christmas Day was spent the in company of his family in the morning and Rachael's family in the evening. He recalled that he went to bed fairly early on Christmas night, at around 8:30pm. When it was put to him in his interview that other family members recalled only leaving the house after 10:00pm, Matt accepted that evidence and said that it felt early to him but he was not sure of the exact time.

Matt told police that, at some point, he woke up to Rachael yelling at him, saying that the house was on fire. He jumped out of bed, and it seemed to him that the fire was at the front of the house and out on the front verandah. He did not think it had started near the Christmas tree. Rachael went to get Sage and Willow from their bedroom at the other end of the house. Matt tried to get Starlia from her bedroom which was adjacent to his, but he could not get past the heat. The intensity of the heat was such that he had to escape out the back door and onto the driveway.

. Matt then remembered laying on the grass near the driveway, where there were lots of

neighbours and people surrounding him throwing water on him. He knew it was too late and his wife and children were trapped in the house. He remembered the ambulance arriving and he asked to be sedated to stop the pain. The Queensland Ambulance Service records indicate that an ambulance was not able to reach the scene until 3:59am.

. With respect to the possible cause of the fire, Matt explained that Rachael was fond of

candles, and paper lanterns that would hold tea lights. He recalled on Christmas night that there were a number of candies lit out on the front verandah but that there were no candles lit inside the house. Some candles were contained inside hanging lanterns.

Rachael’s mother, Susan, and siblings, Angus and Leonie, were also at the home on Christmas evening. Susan and Leonie recalled seeing three lit candles on the dining room table. They also recalled that there were some hanging tea lights on the front verandah as well as some mosquito coils in various positions. Angus also recalled seeing a candle on the dining room table. The dining room table was indicated on diagrams they prepared to be located in the corner of the room, approximately four metres from the Christmas tree.

Findings of investigation into the deaths of Rachel MacCracken, Starlia Golinski, Sage Golinski and Willow Golinski, 2

Angus left the home at around 9:30pm and Susan and Leonie left together at around 10:15pm. Susan sent a text message to Rachael at 11:13pm to arrange a catch up with another brother, Winston, over the next few days. Rachael replied to this text message at 12:16am.

The Christmas tree was a potted live Cyprus pine, and was purchased a few weeks before Christmas. The tree had a strand of Christmas lights on it, which had only been in place since about the week before Christmas. Matt could not recall having any concerns about the lights, but was able to confirm that he was fairly sure they were kept on continuously after they were placed on the tree. They were plugged into a four socket power board which was located behind the tree.

Smoke Alarms

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Matt said there was a smoke alarm near the bathroom and one near the dining room, which he recalled used to go off even when they were boiling water. To his knowledge, the alarm near the dining room was hardwired into the mains power. The alarm near the bathroom was battery operated. He could not remember hearing the sound of an audible alarm on the night of the fire. This was consistent with the large number of statements from neighbours, in which there was only one report of an audible alarm heard. Matt was able to recall that, prior to the fire, neither of the alarms was beeping or making any noises indicating that they required attention.

The police investigation included examination of the smoke alarms within the house. The presence of the two smoke alarms as described by Matt was confirmed. There were no fire sprinklers installed or any other similar fire protection devices.

The investigation was unable to definitively determine what type of smoke alarms were installed. Investigators spoke to the previous owner (and builder) of the house, Edward Cairns, who was an electrician. Mr Cairns believed the smoke alarms were ionic type detectors that he had hardwired into the property. He also thought the alarms were interconnected.

A station officer from QFES, Kyle Dellit, conducted an inspection of smoke alarms that had been installed by Mr Cairns during his construction of an adjoining residence at 13 Jacaranda Place. As these were installed before the construction of 11 Jacaranda Place, it was considered possible that Mr Cairns would have installed the same type of smoke alarm at both houses. Based on this, Mr Dellit concluded the alarms were most likely the ‘ionisation type, 9 volt battery operated, stand-alone smoke alarms.’

QPS investigation findings

Investigating police ultimately concluded that the deaths were a tragic accident. There was no suggestion that the events occurred as a result of an intentional act by any person.

The exact cause of the fire could not be determined due to the extent of the damage to the dwelling.

The smoke alarms failed to perform their role in warning the occupants of the house that the fire had commenced. The house was engulfed by fire by the time the occupants were awake and able to understand what was going on, resulting in Rachael and her daughters not being able to escape from the burning structure.

Police concluded that if the smoke alarms had been functioning effectively, the fire, and consequenily the deaths, could have been prevented. | agree with that conclusion.

Findings of investigation into the deaths of Rachel MacCracken, Starlia Golinski, Sage Golinski and Willow Golinski, 3

Autopsy examination

External autopsy examinations were conducted on each of the children. A full internal examination was conducted on Rachael. All examinations were conducted by experienced specialist forensic pathologist, Professor Peter Ellis, on 29 December 2011.

Professor Ellis also attended the scene of the fire and was present for the location of each of the bodies.

Due to the degree of incineration, the bodies were unidentifiable by visual means and various other examinations were conducted to enable their identification.

Rachael

Positive identification was able to be made by comparing dental records. There was extensive deposition of thick black soot throughout the airway including deep within the lung tissue, indicating active breathing of the soot-bearing smoke.

Relevant to the death, toxicology testing revealed a high saturation of carbon monoxide (73%), being at a level consistent with death.

Professor Ellis determined the formal cause of death to be as a result of smoke inhalation and incineration.

Starlia

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Starlia was able to be indirectly identified by comparing dental records as demonstrating features consistent with her age. Professor Ellis noted an extensive crush injury to the upper half of the head.

Toxicology testing revealed a high saturation of carbon monoxide (48%), being at a level well above what would be considered as fatal. It also supports the premise that Starlia was breathing at the time of the fire and she had breathed in a sufficient amount of smoke to cause this level of carbon monoxide.

Professor Ellis determined the formal cause of death to be from the effects of fire.

Sage

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Sage was able to be indirectly identified by comparing dental records as demonstrating features consistent with Sage’s age.

Toxicology testing revealed a fairly high saturation of carbon monoxide (30%), being at a level above what would be considered as fatal. It also supports the premise that Sage was breathing at the time of the fire.

Professor Ellis determined the formal cause of death to be from the effects of fire.

Willow

Positive identification was able to be made by comparing dental records.

Toxicology testing revealed a moderately elevated level of carbon monoxide (36%), being at a level above what would be considered as fatal. The level is also consistent with active breathing during the fire. Death may have ultimately been caused by a combination of inhalation of toxic gas/smoke and the direct effects of the fire.

Findings of investigation into the deaths of Rachel MacCracken, Starlia Golinski, Sage Golinski and Willow Golinski, 4

Professor Ellis determined the formal cause of death to be from the effects of fire.

Other inquiries

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Throughout the course of my investigation, | have received and had regard to information provided to me by the World Fire Safety Foundation. | am aware that representatives of that Foundation liaised with Detective Senior Constable Hutton throughout the police investigation. The Foundation, among many other organisations, holds concerns about the continued use and the apparent failings of ionisation type smoke alarms. lonisation alarms have been demonstrated to be less effective in detecting smouldering type fires.

Photoelectric alarms respond more rapidly to a broader range of fires and are less likely to cause false alarms.

On 17 November 2014, Coroner McDougall handed down his findings in relation to the Slacks Creek House Fire which occurred in August 2011 and resulted in eleven deaths.

That investigation found that there was no conclusive cause for the fire. In that case, smoke alarms were either not maintained, or were not present. After considering submissions from QFES, Coroner McDougall made a number of comments and recommendations in this regard, which | have reproduced below:

“Legislation should be put in place as soon as possible the effect of which is such that all places where people sleep should be provided with early warning of a fire occurring at a sound level capable of waking them. That is a minimum of 75 Decibels at the bed head. To enable this to be achieved the legislation should provide:-

• That as a minimum in all areas of a building where people sleep, approved smoke alarms are installed:-

a) in any storey containing bedrooms i. between each part of the dwelling containing bedrooms and the remainder of the dwelling and in every bedroom; and

ii, where bedrooms are served by a hallway, in that hallway, and b) in any other storey not containing bedrooms, and

c) in the case where there is more than one alarm required they shall be interconnected by hard wiring where possible and by wireless signal where hard wiring is impractical.

The above implementation should take a staged approach to allow homeowners to prepare for the changes. After the commencement of the legislation, homeowners are required to ensure the new legislative requirements are met in the following circumstances:

• If a dwelling does not have smoke alarms, or does not have smoke alarms that comply with the current legislation, the new legislative requirements must be met immediately for alternatively, within a stipulated period of grace of, say, 6 or 12 months];

• When smoke alarms cease to operate when tested or are at the end of their useful life (10 years from manufactured date);

Findings of investigation into the deaths of Rachel MacCracken, Startla Golinski, Sage Golinski and Willow Golinski, 5

« {f the owner enters into a contract to sell the dwelling, the day before the date of settlement;

• With respect to rental properties, before any new tenancy commences, and within 12 months of the commencement of the legislation in the case of existing tenancies.

• The current legislative requirements continue to apply until the new requirements are met in accordance with this staged approach.

An approved smoke alarm for these purposes means a photoelectric type smoke alarm that complies with Australian Standard AS 3786(Smoke Alarms) and:

a) Ifinstalfed in a newly constructed domestic dwelling, is a 240 volt hard wired smoke alarm, or

b) ff installed in an existing domestic dwelling in addition to, or replacing existing smoke alarms, a 240 voit hard wired smoke alarm where access is available to the ceiling space or, otherwise, a 10 year lithium battery smoke alarm which is interconnected wirelessly, to all other required smoke alarms in the dwelling. It is important that all smoke alarms are interconnected so that if one alarm is triggered all the remaining alarms also operate. This will only be possible if all alarms are the same type and are compatible with each other.

It is also important to say that smoke alarms are only part of the process to ensure people escape to a point of safety from their burning home. A practiced Escape Plan is the other critical component of safe evacuation. It is also recommended that the importance of smoke alarms and other safety requirements such as an Escape Plan be well publicised by QFES and Government. It is hoped that by the full implementation of these recommendations a tragedy such as this will never again occur.”

45. | am also aware that the Senate Legal and Constitutional Affairs References Committee is due to report on 3 December 2015 in relation to its inquiry into the use of smoke alarms to prevent smoke and fire related deaths. | have sent a copy of Coroner MacDougall’s findings to the Committee. A copy of these findings will also be given to the Committee.

The Committee's terms of reference include:

« the incidence of smoke and fire related injuries and deaths and associated damage to property;

« the immediate and long term effects of such injuries and deaths;

e how the use, type and installation set-ups of smoke alarms could affect such injuries and deaths;

e« what smoke alarms are in use in owner-occupied and rented dwellings and the installation set-ups;

e how the provisions of the Australian Building Code relating to smoke alarm type, installation and use can be improved;

e whether there are any other legislative or regulatory measures which would minimise such injuries and deaths; and

«any related matter.

46. The peak body for public sector fire, land management and emergency service organisations in Australia and New Zealand, the Australasian Fire and Emergency

Findings of investigation into the deaths of Rachel MacCracken, Starlia Gotinski, Sage Golinski and Willow Golinski, 6

Service Authorities Council has made it clear that it advocates that all residential accommodation should be fitted with Photoelectric smoke alarms.'

The Queensland Government is yet to respond to the recommendations contained in Coroner MacDougall’s findings in relation to the Slacks Creek House Fire.

Conclusions

48,

Rachael Golinski and her three daughters Sage, Willow and Starlia all died tragically in a house fire in the early hours of Boxing Day 2011. They died after being trapped in their home which was rapidly consumed by fire. The cause of death for each of the children was the effects of fire. Rachael's cause of death was smoke inhalation and incineration.

There is no evidence to suggest that the fire was deliberately lit. Having regard to the evidence of Inspector Dorman, Sergeant Smith and Mr Dall, | conclude that the fire started towards the centre of the home at or near the position of the Christmas tree, which was a Cypress pine with high flammability.

| am unable to find that the fire was caused by candles, having regard to the fact that there was no evidence of candles burning in the vicinity of the Christmas tree on Christmas Day

2011. No candles were located by investigators in the home following the fire.

| conclude that the fire was most likely started from an ignition source located on or immediately below the Christmas tree. Possible sources include a four outlet power board, the 240V Christmas lights and other electrical equipment close to tree,

The family received no warning from the two ionisation type smoke alarms which were installed at the home. The evidence from Matt was that the alarms were in working order, and there was nothing in the lead up to the fire to suggest or warn the family that the batteries needed replacing, or that there was anything operationally wrong with the alarms. It is likely that by the time Matt and Rachael were aware of the fire it had already passed flashover point? and the fire had fully engulfed the house.

After considering the wishes of Matt Golinski, | do not propose to hold an inquest because the investigation has revealed sufficient information to enable me to make the findings required under the Coroners Act 2003.

Having regard to the 2014 recommendations from the Slacks Creek House Fire inquest and the current Senate inquiry, there does not appear to be any prospect of making additional recommendations that would reduce the likelihood of similar deaths occurring in the future or otherwise contributing to public health and safety.

While | do not consider that it is in the public interest to hold an inquest, after consultation with the family, the findings will be published in accordance with section 468A of the Coroners Act 2003.

1 Submission by the Australasian Fire and Emergency Service Authorities Council to the Senate Legal and Constitutional Affairs References Committee, August 2015.

2 A flashover occurs when ail combustible materials in a room or compartment reach their ignition temperatures at the same time. This can occur in as little as 2-3 minutes.

Findings of investigation Into the deaths of Rachel MacCracken, Starlia Golinski, Sage Golinski and Willow Golinski, 7

Findings required by s. 45

Identity of the deceased:

How she died:

Place of death: Date of death:

Cause of death:

Identity of the deceased:

How she died:

Place of death: Date of death:

Cause of death:

Identity of the deceased:

How she died:

Place of death: Date of death:

Cause of death:

Rachel Naomi Hannah MacCracken

Rachel and her three daughters died tragically in a house fire in the early hours of Boxing Day 2011. They died after being trapped in their home which was rapidly consumed by fire. The fire was most likely started from an ignition source located on or immediately below a Christmas tree. Possible sources include a four outlet power board, the 240V Christmas lights and other electrical equipment close to the tree.

11 Jacaranda Place, Tewantin QLD 26 December 2011

Smoke inhalation and incineration.

Starlia Golinski

Starlia, her mother and two sisters died tragically in a house fire in the early hours of Boxing Day 2011. They all died after being trapped in their home which was rapidly consumed by fire. The fire was most likely started from an ignition source located on or immediately below the Christmas tree.

Possible sources include a four outlet power board, the 240V Christmas lights and other electrical equipment close to the tree.

11 Jacaranda Place, Tewantin QLD 26 December 2011

Effects of Fire

Sage Golinski

Sage, her mother and two sisters died tragically in a house fire in the early hours of Boxing Day 2011. They died after being trapped in their home which was rapidly consumed by fire. The fire was most likely started from an ignition source located on or immediately below a Christmas tree. Possible sources include a four outlet power board, the 240V Christmas lights and other electrical equipment close to the tree.

11 Jacaranda Place, Tewantin QLD 26 December 2011

Effects of Fire

Findings of investigation into the deaths of Rachel MacCracken, Starlia Golinski, Sage Golinski and Willow Golinski, 8

Identity of the deceased:

How she died:

Place of death: Date of death:

Cause of death:

| close the investigations.

Terry Ryan

State Coroner Brisbane 23 November 2015

Willow Golinski

Willow, her mother and two sisters died tragically in a house fire in the early hours of Boxing Day 2011. They died after being trapped in their home which was rapidly consumed by fire. The fire was most likely started from an ignition source located on or immediately below a Christmas tree. Possible sources include a four outlet power board, the 240V Christmas lights and other electrical equipment close to the tree.

11 Jacaranda Place, Tewantin QLD 26 December 2011

Effects of Fire

Findings of investigation into the deaths of Rache! MacCracken, Starlia Golinski, Sage Golinski and Willow Golinski, 9