Record Of Investigation into Death

Coroners Act 1995
Coroners Regulations 1996
Regulation 14
Form 4

I, Stephen Raymond Carey, Coroner, having investigated the death of

Bryan Eldred TEMPLER


Find That :

(a) The identity of the deceased is Bryan Eldred Templer ("Mr Templer") who died on 2 February 2011.

(b) Mr Templer died in the residency area at the May Shaw Health Centre in Swansea.

(c) Mr Templer was a divorced person and was aged 72 at the date of his death, having been born on 13 June 1938 in England.

(d) Mr Templer died as a result of acute smoke inhalation. Significant contributing factors were oxygen dependent emphysema, non-small cell lung cancer and severe atherosclerotic coronary vascular disease.

Circumstances Surrounding the Death :

After immigrating to Australia Mr Templer settled in the Huon Valley in Tasmania where he purchased a farm and grew vegetables. In 1974 he married June Morris, however shortly after the birth of their child Mathew James Morris in that year the marriage broke down and he left the relationship. He did not have any contact with his son until about 1992 and since that time Mr Templer and his son have only met approximately five times.

In around 2001 Mr Templer moved to Swansea and rented a house approximately 8kms north of the township. In 2003 Mr Templer commenced consulting Dr Andrew Grove who diagnosed that Mr Templer was suffering chronic obstructive pulmonary disease (COPD). Mr Templer advised that he had been a smoker since the age of 17 and he indicated to Dr Grove that he was not going to cease smoking despite suffering his health condition. Over the next three years Mr Templer's condition deteriorated and after referral to Dr Hugh Mestitz, a respiratory physician, he was in November 2007 provided with home supplementary oxygen therapy. By October 2008 it was noted by Peter Willoughby, social worker from the Community Health Services, that Mr Templer's living conditions were poor and assistance was organised to help him with basic household chores and financial management. At this time Ms Cynthia Trezise, who had befriended Mr Templer over the years, was employed to assist him under a home help scheme. She provided basic domestic household duties on a fortnightly basis. Ms Trezise noted that as time progressed Mr Templer's health deteriorated and he became less mobile.

In June 2010 Mr Templer accepted that he required ongoing care and he was admitted to the May Shaw Health Centre as an acute patient as he was unable to care for himself due to the exacerbation of his COPD. Upon his admission he was set up in Room 60 which was in the Oyster Bay Wing of this Centre. His 24 hour supplementary oxygen therapy continued whilst he was at the facility. Initially Mr Templer was restricted in his ability to mobilise due to his breathing difficulties. However some months after his admission he purchased a motorised scooter and this allowed him to be more mobile and to move around within the facility.

Not long after his admission to the facility the Chief Executive Officer Ms Julie Orr had reason to talk to Mr Templer after the smell of cigarette smoke was detected in the ensuite of his room. During this conversation the rules regarding smoking at the facility were reiterated to Mr Templer. He agreed to follow the rules which stipulated that smoking was only to occur in the designated smoking area which was a courtyard at the facility. Notwithstanding this, staff did suspect on other occasions that he may have occasionally smoked in his room, however he always denied this when questioned. By late January 2011 nursing staff notes indicate that Mr Templer had been experiencing breathing difficulties at various times during the day and night and that he had indicated to the staff that he was feeling weak and was talking about wanting to die due to his inability to breath properly. At times he was noted to appear confused and to be more anxious than usual. He was not eating regularly, refusing to take his medication and waking during the early hours, complaining of pain.

Mr Templer was seen by Dr Grove in his room during the afternoon of 28 January 2011 at which time the staff notes indicate that he was mildly confused and that he was prescribed an increase in his dosage of nortriptyline. Over the next few days he continued not eating regularly, refusing to take medication at times and was still in a confused state. Staff also indicated that he was difficult to understand and that he refused basic care on a number of occasions.

On the evening of 1 February 2011 at about 5.00 pm he rang his call bell and advised staff that he was dying. Observations were done by the enrolled nurse on duty and his oxygen saturation levels were noted to be very low. His oxygen supply was increased from 2L/min to 4L/min. After 20 mins his oxygen saturation levels had increased to 95% and the oxygen level was reduced to 3L/min. Staff returned later to give him his evening medication and he was noted to be in a deep sleep. During the early hours of 2 February 2011 the deceased rang his call bell on a number of occasions. Notes indicate that he was confused as to what time it was and wanted to know when his breakfast was coming. Staff reassured him that it was too early for breakfast and he was given his evening medication that he had not yet taken. He slept well for the remainder of the night. At 6.00 am staff gave him his morning medication and they encouraged him to breathe through his nose instead of his mouth as he had oxygen tubing in his nose and it would help his breathing. Staff then left and attended to other residents prior to attending the morning staff handover at 7.00 am.

At 7.19 am on 2 February 2011 the fire alarm activated in room 60 in the Oyster Bay Wing. Tasmanian Fire Service was notified by direct alarm from the May Shaw Centre to Fire Communication Centre in Hobart. The Swansea Volunteer Fire Brigade were then paged to attend the alarm.

At the same time registered nurse Judy Moore assumed the role of Chief Fire Warden and directed registered nurse Aneesh Pillai, together with Melissa Pitstock and Lynne McMahon to investigate the fire alarm in room 60. Upon reaching the Oyster Bay Wing Mr Pillai reports that he could smell smoke. Once outside room 60 it was noted that a small amount of smoke was visible coming from underneath the door. Mr Pillai opened the door and saw the foot end of the bed on fire. Mr Templer was sitting on his scooter near the end of his bed and there was a line of fire on the floor near the foot of the bed to the scooter. It was also noted that flames were coming from the bottom of the bed and it appeared that the oxygen tubing from Mr Templer's oxygen bottle to his nose had burnt and that he had also suffered burns to his face and hair.

Staff called out for Mr Templer to move to them and Mr Pillai obtained a nearby fire extinguisher, but before he could activate this the automatic sprinkler system in the facility activated and extinguished the fire. The staff noted Mr Templer get off his scooter and start walking towards them, however the smoke had become very thick inside the room and was spreading throughout the entire Wing. Registered nurse Moore as the Chief Fire Warden then ordered the evacuation of all other residents from that Wing. Mr Pillai was able to grab hold of Mr Templer as he walked out of room 60 but Mr Templer seized hold of the railings outside his room and pulled away from Mr Pillai. Mr Pillai lost his grip on the deceased and saw him walk over to the opposite side of the hallway. The smoke became even more dense and Mr Pillai was obliged to pull back as he could no longer see Mr Templer due to poor visibility. Staff members Mr Pillai and Ms Pitstock and Ms McMahon were able to then evacuate all other residents in this Wing, taking them to the dining area, save for Mr Templer and the occupant of room 59, Mr William Coleman. The smoke continued to spread and affected the Apsley Wing which was then ordered to be evacuated as well. The Chief Executive Officer of the facility, Ms Julie Orr, Dr Andrew Grove and Dr Camilla Byrne were contacted to attend together with extra nursing staff and careers.

The Swansea Volunteer Fire Brigade arrived at the scene at 7.32 am. Mr Kelvin Jones and Bob Moore donned breathing apparatus and entered the Oyster Bay Wing at approximately 7.38 am. They found that visibility was very poor due to the amount of smoke in the environment. They searched each room in turn and located Mr Templer laying on the floor in the hallway outside the doorway of room 59. Mr Moore returned to the fire door leading into Oyster Bay Wing where he was provided with a hospital bed upon which Mr Templer was placed and then evacuated from the Wing. Nursing staff met the fire fighters at the fire door and took Mr Templer to the emergency room where he was placed on oxygen, however physical examination conducted at the time disclosed no signs of life and he was declared dead by Dr Camilla Byrne.

Messrs Jones and Moore resumed the search in Oyster Bay Wing and located in room 59 Mr William Coleman. They wheeled his bed to staff who were waiting at the fire door. He was taken to the emergency room and treated for smoke inhalation and recovered after several hours of oxygen therapy. Messrs Jones and Moore concluded their search within the Oyster Bay Wing and no other persons were located. All residents at the facility were accounted for and action was then taken to ventilate the area and clear the smoke.

Police cordoned off the Oyster Bay Wing and secured the scene, awaiting the arrival of a fire investigator, Aurora investigator, CIB and police forensic services. A fire investigation was conducted by Mr Adam Meredith, Regional Fire Investigator of Tasmanian Fire Service. Mr Meredith has provided a detailed investigation report. As to the cause of the fire, I note the following from his report;

"My investigation then turned to determining the cause of the fire. I noted a molten line in the carpet which led from the bed to the motorised scooter that Mr Templer was sitting in when the first registered nurse went to investigate the alarm. This was found to be an oxygen line leading from the oxygen machine to Mr Templer, supplying him with oxygen via nasal prongs. It was found that the oxygen line had melted and burned from the point of origin back towards the oxygen machine and also to Mr Templer as portions of the melted plastic tubing was located on the left side of the deceased's head, in his hair behind his left ear.

I then began examining the point of origin. Within the immediate area there were no possible ignition sources and the only items located in this area was a long sleeved blue and white synthetic shirt along with a pair of sandshoes.

The shirt had been severely damaged by fire and this was to be deemed as the lowest point of fire damage that had occurred to the room. The pair of sandshoes had a hole in the right shoe towards the rear and there was no fire damage to the left shoe, which indicated to me that the fire had travelled to the shoe from the right side; this was where the synthetic shirt was located.

The fire damage and burn patterns to the hospital bed were the next item I processed. The damage to the bed clearly indicated that the fire had originated from the floor to the left side of the bed towards the foot area with substantial burning occurring to the underside of the mattress. There was also a small half-moon burn pattern that had occurred to the left side of the bed directly above where the synthetic long sleeve shirt was located. A V pattern was also evident directly above the synthetic shirt in the form of the removal of paint located on the bed frame caused by direct flame contact in this area.

With this evidence I deem the long sleeve blue and white striped synthetic shirt to be the point of origin."

Mr Meredith then considered how the synthetic shirt became involved in the fire. He noted evidence in the form of a cigarette butt in the room and a cigarette lighter (black Bic lighter) was located in the corridor where Mr Templer collapsed after removing himself from the room. Given that there had been previous incidents where it was suspected that Mr Templer had smoked in his room, it is a reasonable conclusion given this evidence that on this morning he had also lit a cigarette. His reason for doing this may have been a deliberate breach of the rules which he was well aware of or alternatively caused by his confused state that had been developing over the previous days. In any event Mr Meredith concluded that the most likely scenario was that the synthetic blue and white shirt was in the vicinity of Mr Templer when he lit his cigarette whilst sitting on his scooter. For some reason, either due to his failing eyesight, or confused state, or general restlessness following an unsettled night, he has accidentally ignited the shirt whilst lighting his cigarette, or perhaps the cigarette has in some way ignited the shirt. As the fire became apparent Mr Templer has then stood up and the shirt , now alight, has fallen on or near the end of the hospital bed causing this to ignite. Mr Templer has failed to recognise the danger of the burning shirt and has remained on his scooter, possible smoking his cigarette. The shirt has burned, causing flames to come into direct contact with the bedding sheets and the bed¡¦s mattress. The bedding material has then created sufficient smoke for the alarm to be activated, however as the fire was burning the underneath of the mattress insufficient heat had been released in the early stage to activate the ceiling sensor of the sprinkler system which is set at 68 degrees Celsius. Mr Meredith concludes, and I accept his conclusion, that the fire was accidental in nature with the cause being accidental ignition of a synthetic long sleeve shirt with the use of a mobile ignition source in the form of a cigarette lighter whilst in the process of igniting a cigarette.

Comments and Recommendations :

As a result of this incident a review was conducted by May Shaw Health Centre of their fire safety policies and procedures. As result of this a number of changes were implemented. This incident highlights the need not only to ensure staff training occurs as to fire emergency procedures, but also existing procedures and policies are independently assessed on a regular basis by an external expert in this field. The changes implemented are set out herein for guidance and information of other like care facilities. The changes are as follows:

  • Exit ramp at rear of building was extended to allow for easier evacuation.
  • Lifting sheets placed at all exits where there are stairs and staff educated in their use.
  • Increased exit signage and improved visibility of other exit signs in the building.
  • Signage to indicate designated smoking areas and non smoking areas.
  • Pruning of foliage around the smokers' courtyard to allow better visibility, particularly from the nurses' station.
  • Review of all fire systems by external contractor in consultation with Tas Fire Service.
  • Policy re smoking has been reviewed to include clause prohibiting any resident or patient having cigarettes/lighters in their possession while they require supplementary oxygen. A contract agreeing to this limitation has to be signed.
  • Introduction of a contract by all smokers acknowledging that they will wear a smoking apron when smoking unattended.
  • Review of the Resident Handbook and Resident Agreement to include new smoking provisions.
  • Review of Smoking Risk Assessment form.
  • Updating of the documentation to ensure monthly checks, both internal and external, contractors reflect completion of all works.
  • Introduction of the "Emergency Response Afterhours" folder to improve safety and communications during times of minimal staffing. Will direct staff on necessary immediate actions in case of emergency and contains a master key to allow unlocking of residents' rooms immediately. This was identified as a problem during the fire as the Deputy Warden had to leave her post to unlock resident rooms, using up valuable time during the evacuation.
  • Automatic update of all residents/patients in the facility is now generated by night staff and placed in the necessary areas.
  • Compulsory fire training is now conducted six monthly to ensure all staff in the facility receive this training without delay. Previously it was only conducted annually so new staff may well have waited 11 months before proper training completed.
  • Local fire brigade visit the facility three monthly.
  • Fire training on the night shift (minimal staffing) with external provider will be conducted as a separate process.
  • The policy has been introduced to notify all relevant agencies and organisations in the event of another major incident within the facility.

Some consideration and debate surrounded the involvement of the supplementary oxygen being used by Mr Templer at the time of the fire. Whilst oxygen is not itself flammable, its presence would ensure that any fire would burn hotter and faster. In this case I am satisfied that the risks of combustion were well documented on the equipment and also known to Mr Templer. It is of concern however that there were clearly incidents where staff suspected that Mr Templer was smoking in his room whilst using the supplementary oxygen. Not only was this contrary to the rules concerning smoking, but also staff ought to have been aware of the added risk that this created. In my view it would be worthy to consider that where there is a breach of the no smoking rules within a care facility such as this that a resident/patient should have any ignition source removed from their possession. In those cases the person would be provided the ignition source only upon request and when they were located in the smoking area.

This incident could have had led to a catastrophic outcome had not the facility been given early warning by its fire detection system and its staff reacted professionally when the alarm sounded. My only concern in relation to this investigation is that Mr Templer had given previous indications of being non-compliant but was still able to maintain possession of an ignition source whilst using supplementary oxygen. As outlined above I would recommend the removal of the risk of further breach by such non-compliant residents. The limitation of personal freedom is to be preferred to the risk of harm to the person or to others.

Before I conclude this investigation I wish to convey my sincere condolences to Mr Templar's family.

DATED this 19 day of December 2011 at Hobart in Tasmania


Stephen Carey