Following the tragic death of Mrs Sonia Sofianopoulos in July 2017 and subsequent Coronial Inquest, Coroner Jacqui Hawkins handed down her findings earlier today.
Coroner Hawkins found that Mrs Sofianopoulos died as a result of carbon monoxide poisoning and that the source of the carbon monoxide was most likely a faulty 25 year old Vulcan Heritage gas space heater Series 48. The Unit in which Mrs Sofianopoulos lived had little open ventilation and, therefore, the operation of one or more extraction fans in the kitchen and bathroom respectively, could result in a negative pressure in the Unit which could reverse the direction of flow of combustion products in the flue of the open flued gas heater (OFG heater), drawing flue products into the Unit.
Following a thorough investigation and inquest Coroner Hawkins made eight recommendations as set out below:
1. I recommend that Chris Wealthy, the Chief Executive Officer of The Australian Gas Association and Paul Fearon, the Chief Executive Officer of Energy Safe Victoria, collaborate to implement a strategy and plan to phase out all OFG heaters.
2. I recommend that John Bradley, the Secretary of Department of Environment Land Water and Planning, conduct a Regulatory Impact Statement to consider the implementation of a system of mandatory continuous professional development training for Type A Gas Appliance plumbers and fitters as a condition of being registered or licenced.
3. I recommend that Timothy O’Leary, the Chief Executive Officer of Climate Technologies Pty Ltd. as the manufacturer of the Vulcan/Pyrox Heritage OFG Heater, publish an article in The Age and the Herald Sun warning the public, especially those that have this type of heater installed in their homes, about the necessity of regular servicing and maintenance. This is to ensure that it operates in a safe and efficient manner and does not expose residents to carbon monoxide poisoning under the conditions that have been identified in this Inquest.
4. I recommend that Paul Fearon, the Chief Executive Officer of Energy Safe Victoria, publish an article in their quarterly newsletter about the importance of testing for carbon monoxide spillage and provide guidance as to appropriate detection equipment to use to obtain the most accurate results and to ensure the safety of the users.
5. I recommend that Sue Eddy, the Chief Executive Officer of the Victorian Building Authority, consult with relevant industry stakeholders and review its requirements for the provision of Certificates of Compliance to the extent that they relate to the servicing, testing and maintenance of OFG heaters.
6. I recommend that Enzo Alfonsetti, as Chairman of the Standards Australia – Committee Responsible for Australian Standard: 4575 Gas Appliances – Quality of Servicing to consider amending that standard to incorporate Appendix R of AS5601 as soon as practicable.
7. I recommend that Paul Fearon, the Chief Executive Officer of Energy Safe Victoria, conduct a review on the best way for Energy Safe Victoria to communicate guidelines, changes to legislation and industry updates to relevant stakeholders using all forms of modern technology including phone applications, social media and YouTube videos.
8. I recommend that Paul Fearon, the Chief Executive Officer of Energy Safe Victoria, conduct a widespread media and public awareness campaign on the dangers associated with OFG heaters, especially in the context of negative pressure and lack of adventitious ventilation and the need and importance of servicing and maintaining OFG heaters.
We understand that Coroner Jacqui Hawkins’ full finding will be posted on the Coroners Court of Victoria website and can be viewed at:
Finally, we extend our heartfelt condolences to the Sofianopoulos family and those affected by their tragic loss.