Coroner's Finding: de-identified GN

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 (These findings have been de-identified in relation to the name of the deceased, family, friends, and others by direction of the Coroner pursuant to s57(1)(c) of the Coroners Act 1995) I, Robert Webster, Coroner, having investigated the death of GN Find, pursuant to Section 28(1) and 45(1) of the Coroners Act 1995, that a) The identity of the deceased is GN b) GN died in a shed fire; c) GN’s cause of death was thermal burns due to a shed fire; d) GN died on 30 November 2022 at Mowbray in Tasmania; e) The cause and origin of the fire is the presence of accelerant (contained in fuel containers stored in the shed) which has produced a large amount of flammable vapour which has ignited with the introduction of a mobile ignition source; f) The circumstances in which the fire occurred are set out below; and g) I am unable to determine, on the basis of the evidence, the identity of the person who contributed to the cause of the fire other than to say GN and HU were in the vicinity of the shed at the time the fire commenced.

Introduction In making the above findings I have had regard to the evidence gained in the comprehensive investigation into GN’s death. The evidence includes:

• The Police Report of Death for the Coroner;

• Affidavits as to identity and report of the forensic scientist Ms Rebecca Wilson of Forensic Science Service Tasmania;

• Affidavit of the forensic pathologist Dr Christopher Lawrence;

• Affidavit of the forensic scientist Mr Neil McLachlan-Troup of Forensic Science Service Tasmania;

• Records obtained from Ambulance Tasmania (AT);

• Records obtained from the Launceston General Hospital (LGH) and the Royal Hobart Hospital (RHH);

• Video recorded interview with HU;

• Affidavits of IV;

• Affidavit of TW;

• Affidavit of JV

• Affidavit of KQ;

• Affidavit of Mr David Binns;

• Affidavit of Ms Kristy Norgaard;

• Affidavit of First-Class Constable Nigel Housego;

• Affidavit of Senior Constable Michal Rybka;

• Affidavit of Constable Matthew O’Neil;

• Affidavit of Senior Constable Thomas Moir;

• Affidavit of Senior Constable Robert Shepherd;

• Affidavit of Senior Constable Ashlee Goss;

• Affidavit of Sergeant David Gammon;

• Affidavit of Constable Damien Springer;

• Affidavit of Detective Senior Constable Russell Forsyth;

• Affidavit of Detective Constable Kelly Hindle;

• Affidavit of Senior Constable Caroline McGregor;

• Tasmania Fire Service (TFS) report; and

• Body worn camera footage, scene footage, 000 calls photographs and forensic evidence.

Background GN was born at the LGH on 23 September 2019. His parents are IV and OX. They separated after being together for approximately four and a half years when GN was six months old. GN was just over three years of age at the date of his death. He was a healthy child with no medical issues.

In 2021 IV commenced a relationship with TW to whom she had a son, PS, in April 2022.

During that pregnancy IV and GN moved in with TW at his rental home situated in Mowbray. TW and GN had a very good relationship.

In addition to IV, TW and the two children, JV lived in the house. The three adults all smoke cigarettes and they each used lighters, which they would leave in many different places but generally up on a table or a shelf. IV says they never left any outside and none of them had a favourite or specific coloured lighter.

GN would see the adults smoking and IV confirms they have lit cigarettes in his presence but he has never used or even tried to use a lighter. In addition, to the right of the home is a driveway at the end of which is a double lock-up garage. There is a fire pit in the driveway which the family uses to burn rubbish. IV says GN has been outside with the adults when the fire pit has been operating but he has never been with them when they have started the fire pit. They have in the past used petrol to start the fire pit and although GN has never been present when this has occurred he may have been watching from inside the house. In addition she says he was not allowed to play with the fire or help light a fire. They would use a cigarette lighter to start a fire.

To the left of the double lock up garage is a grassed area to the rear of which is a small wooden footbridge that leads to a further backyard at the rear of the property that contains a washing line and a tin garden shed which measured approximately 3 m x 3 m which is situated at the back left-hand corner of the property. To the right of the shed is a grassed area where a circular trampoline and plastic slide were situated. From the rear of the house to the shed is a distance of approximately 20.5 m.

IV says a rabbit hutch was stored in the garden shed and in addition there were two jerry fuel cans which were stored to the right by the door as you walked into the shed but on the ground. One of the jerry cans was empty and the other was about half full of petrol which was used to operate the lawnmower. There was no shelving in the shed. IV believes they kept a slide in the shed as well which was dark green and plastic and it had a metal ladder.

TW says in addition there was a few tables and chairs and some mulch and soil stored in the garden shed. The petrol was kept in this shed because GN was not permitted in that shed.

He was permitted in the main garage. IV says her son knew he was not allowed in the shed and to her knowledge he had never gone into that shed. She said it was always closed with a slide bolt lock which she does not believe he would be able to open because it was quite stiff and one had to lift the door on a certain angle to open it. There was no power source in the shed and no extension cords running to the shed.

It was common for IV to babysit KQ’s two children namely HU and ZS. This enabled KQ to go to work. HU was four years of age and ZS was one at the time of the incident the subject of this investigation. KQ believes her son has global developmental delay, a speech impediment and perhaps autism. Both IV and KQ say if you know HU you can understand

what he is saying but otherwise he is difficult to understand. She says HU has observed her smoke and has passed her a lighter previously but she has never seen him try to use one.

Her partner, AM, does not smoke.

IV says the four children got on really well together. She says the two boys were always getting into things they were not meant to but they knew she had a number of rules which they complied with which were that they were never to go into the back shed, they were never to open the front gate and they were not to hit one another.

Circumstances Leading to Death On 30 November 2022 TW got up at around 5.30am, smoked a cigarette and then had a shower. He left for work at around 6.15am. At approximately 8.00am, KQ dropped her two young children off for IV to babysit. KQ then went to work.

During the morning GN and HU played both inside the house and outside the house. ZA and PS remained inside with IV. At around lunchtime GN was reprimanded as he had used a heap of toilet paper to clog up the toilet. At approximately 1.00pm JV went to have a shower. IV had set ZS on the couch and was walking PS into his room to give him a bottle when she heard what sounded like an explosion and then HU screaming for help.

IV ran outside and saw smoke coming from the rear garden shed. She could hear GN. She ripped the door of the shed open (it wasn’t locked but had swung closed) but she could not see GN. She was unable to retrieve him due to the intensity of the smoke and the heat.

At the time she ran out the back HU had run along the left side of the house and had come through the front door. He then followed IV out to the backyard. She could see his face was red and his hair singed around the front and on top. He was yelling out for help. IV ran back inside and grabbed JV from the shower before they ran back to the shed in an effort to save GN who they could still hear. JV recalls seeing black smoke coming from the rear of the shed and flames coming out of the shed. He tried to go into the shed but it was simply too hot. At about this time a neighbour, Mr Binns, heard the commotion and jumped the fence to assist. He observed HU had burns to his arms and legs. They then used buckets of water and a garden hose to try and extinguish the fire. Mr Binns says he continued hosing for about 5 minutes and he was holding the door of the shed open with a branch from a distance due to the heat. JV again tried to enter the shed but could not do so due to the intensity of the heat and smoke. He advised IV there was nothing that could be done and that GN was gone.

At around this time a neighbour Ms Norgaard appeared in the yard and accompanied IV away from the rear section of the yard.

First-Class Constable Housego was the first emergency service worker to arrive at the scene. He was accompanied by Constables Rybka and O’Neil. He observed IV and Ms Norgaard standing on the footpath at the front with HU in an obviously distressed state.

First-Class Constable Housego ran to the rear of the yard and observed Mr Binns still hosing the shed from a distance of about 2 to 3 metres away. He could not see in the shed due to the dark smoke and steam being emitted. He took the hose from Mr Binns and sprayed the water so that it spread around the shed. As it did so visibility improved and he could see what he believed to be a child on the floor of the shed. He formed the view, given what he observed, GN was deceased.

Detective Constable Moir turned up soon after at about the same time as members of the TFS. He relieved First-Class Constable Housego. Further police arrived soon after followed by members of AT.

IV and HU were transported from the scene to the LGH. IV was treated for injuries to both hands, smoke inhalation and shock. HU was later flown to the RHH for treatment relating to his burns.

Investigation The scene was immediately secured by police and an investigation commenced by members of the Northern Criminal Investigation Branch and Northern Forensics of Tasmania Police and TFS fire investigators. The scene was examined and photographed. Items were removed from the shed and fire scene examiners located an area which represented the possible fire seat in the front right area of the shed where a plastic fuel container and cardboard box were located. The cardboard box remnants smelled strongly of fuel and the pooling of fuel was present around this area. There was no evidence or remnants of a cigarette lighter located. However one cigarette lighter was found at the base of the clothesline whereas another was found on a table which was part of an outdoor setting situated on the rear porch of the property. A third cigarette lighter was found on a table located in the double garage.

Statements were taken by police from relevant witnesses and attempts were made to interview HU but his communication skills were very limited and he was very difficult to understand. From this interview I am unable to determine exactly how the fire started and who was responsible. The only clear information obtained from HU is that it was GN who opened the door to the shed and he went inside.

The fire investigators were Mr Anthony Goss and Mr James Foster. Mr Goss in his report says in addition to the front door to the shed there was a glass louvre window to the left of

the front door. The shed was built on a concrete slab. The items observed in the shed included the remains of pet food pellets, laminated unidentified timber products, Mother’s Choice brand timber cot, a melted purple plastic container, an unidentified melted blue plastic item, guinea pig pet food pellets/grain mix, two square tabletops, metal bases for the tables, animal bedding and sawdust, a metal frame believed to be from a slide with melted green plastic beneath the slide’s frame, and the remains of two fuel containers and two chairs. The shed’s contents were removed and an irregular burn pattern was observed on the concrete slab which is said to be likely the result of flammable liquid being present in that area. The pattern represented the shape of a spalling pattern. Towards the middle of the shed near the location of the fuel containers irregular burn patterns on the concrete slab along with spalling to the concrete was observed. The spalling is likely to result from a flammable liquid being spilled, dropped or poured. Some evidence was removed for sampling. It was noted the shed was not energised and there were no identifiable items in the shed to indicate spontaneous ignition. There were no ignition sources identified within the shed and accordingly a mobile ignition source was considered to be the most likely source in this case. The gas lighter found at the foot of the clothesline was approximately 2 to 3 metres from the door to the shed.

It seems from what Mr Goss found the two plastic red petrol containers appear to have been moved from near the doorway where IV says they were stored to the rear left area of the shed where they were located by investigators.

As a result of his assessment of the scene and consideration of all of the evidence Mr Goss says he believes: “… There has been an accelerant introduced to the shed, most likely from the fuel containers found within the shed. Accelerant has likely been added to combustible materials within the shed. There has been enough accelerant to produce a large amount of flammable vapour to generate a volatile atmosphere with the introduction of a mobile ignition source, most likely by either of 2 persons present at the time of ignition. The result has been the ignition of flammable vapour, generating rapid evolution of combustion, which would have initially consumed the flammable vapour, engulfing the available internal shed area. The initial vapour has been consumed; combustion has been sustained to the denser combustible material at the right hand side of the shed. These combustible materials have continued to burn due to accelerant being added to them.

The radiant heat from combustible materials on the right-hand side of the shed has softened and melted the plastic component slide. The deceased’s weight has pulled the

metal framework steps of the slide in the direction of the deceased as the slide has decayed.

The deceased was in a position indicating crouching, shielding, and hiding, strongly suggesting the radiant heat from the right-hand side of the shed was preventing self extrication.

The appearance of redness to the exposed areas of the infant that was able to get outside the shed suggests that they would have been in a location that has subjected their legs, arms and head to high temperature. I would not expect to see injury sustained to the exposed areas of the infant if they were in a position remote from combustion, which suggests they were likely in the shed or very close to the entrance at the time of vapour ignition.

I did not observe signs of overpressure to the shed, which suggests that as the vapour has rapidly ignited, the door to the shed has either been open or flung open to release the pressure build-up. The only ignition source identified was a gas lighter found near the clothesline, which is the most likely ignition source.

I found no evidence or information to suggest that the cause of this fire was associated with a spontaneous, electrical, chemical, or deliberate cause.” Mr Goss determined the cause of the fire to be accidental. I accept his opinion.

Dr Lawrence conducted a post-mortem examination on 1 December 2022. As a result of his examination of GN, Dr Lawrence determined GN died of thermal burns due to a shed fire.

The autopsy revealed extensive burns, clear soot in the trachea and pink blood consistent with smoke inhalation. On testing there was a low carbon monoxide percentage which Dr Lawrence says may be accounted for by an explosion which was heard by witnesses which suggests to Dr Lawrence a sudden rapid spread of the fire. I accept his opinion.

Comments and Recommendations I am satisfied there are no suspicious circumstances and there is no evidence of a third person being involved in this shed fire. The cause is accidental. I am satisfied an accelerant was introduced into the shed from the fuel containers stored therein. A mobile ignition source has then been introduced which has ignited the vapour causing an explosion which has then led to the combustion of the contents of the shed. As I have previously mentioned the state of the evidence is such that I am unable to determine the exact role played by GN and HU in causing the fire.

This very tragic event has had life changing effects on not only one but two families and their friends. In these circumstances it is very important to recommend to parents of children that they properly educate their children about the dangers surrounding fire. I also recommend parents are vigilant and not permit their children access to mobile ignition sources such as lighters and/or matches or any flammable liquids. Mobile ignition sources and flammable liquids should be stored in such a way that they are inaccessible to children.

I extend my appreciation to investigating officer Senior Constable Kelly Hindle for her very thorough investigation and report.

The circumstances of GN’s death are not such as to require me to make any further comments or recommendations pursuant to Section 28 of the Coroners Act 1995.

I convey my sincere condolences to the family and loved ones of GN.

Dated: 9 August 2023 at Hobart in the State of Tasmania.

Robert Webster Coroner