Finding into death of Jeffrey Thomas Wilson

IN THE CORONERS COURT COR 2024 007551 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: AUDREY JAMIESON, Coroner Deceased: Jeffrey Thomas Wilson Date of birth: 1 May 1948 Date of death: 30 December 2024 Cause of death: 1a: Effects of fire due to home oxygen ignition in the setting of smoking 2: Lung cancer Place of death: Unit 3, 1 Glenvale Road Mount Clear Victoria 3350

INTRODUCTION

1. On 30 December 2024, Jeffrey Thomas Wilson was 76 years old when he died after his home oxygen set alight when he lit a cigarette. At the time of his death, Jeffrey lived in Mount Clear with his son, Luke.

2. Jeffrey had a 60-year history of smoking and a 20–30-year history of exposure to asbestos. In October 2024, he was diagnosed with mesothelioma. He was functionally independent but was mostly housebound due to shortness of breath.

THE CORONIAL INVESTIGATION

3. Jeffrey’s death was reported to the coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (the Act). Reportable deaths include deaths that are unexpected, unnatural or violent or result from accident or injury.

4. The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death, and surrounding circumstances. Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death. The purpose of a coronial investigation is to establish the facts, not to cast blame or determine criminal or civil liability.

5. Under the Act, coroners also have the important functions of helping to prevent deaths and promoting public health and safety and the administration of justice through the making of comments or recommendations in appropriate cases about any matter connected to the death under investigation.

6. This finding draws on the totality of the coronial investigation into the death of Jeffrey Thomas Wilson. Whilst I have reviewed all the material, I will only refer to that which is directly relevant to my findings or necessary for narrative clarity. In the coronial jurisdiction, facts must be established on the balance of probabilities.1 1 Subject to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336. The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals unless the evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments.

MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Circumstances in which the death occurred

7. Jeffrey was admitted to Grampians Health Ballarat on 30 November 2024 with shortness of breath. The State-wide Equipment Program (SWEP)2 was consulted regarding home oxygen supply, but they advised that Jeffrey did not meet the eligibility criteria due to his recent smoking history. Jeffrey was discharged home on 6 December 2024 with home oxygen provided by an external supplier.3 The discharge summary requested that Jeffrey’s GP re-refer him to Grampians Health to obtain funded home oxygen following cessation of smoking.

8. Jeffrey was admitted to Grampians Health Ballarat on 18 December 2024 and was diagnosed with community acquired pneumonia and infective exacerbation of chronic obstructive pulmonary disease (COPD). Progress notes from this admission note that he had not smoked since before his prior admission.

9. Jeffrey was reviewed by the palliative care team and agreed to ongoing community-based palliative care services. The palliative care notes state that that Jeffrey was on self-funded home oxygen as he had recently ceased smoking.

10. Jeffrey was discharged home on 22 December 2024. The discharge summary for the admission documented that Jeffrey stated that he had quit smoking yet continued to light approximately five cigarettes per day, taking a single puff without inhaling.

11. On 27 December 2024, Jeffrey was conveyed to the Grampians Health Ballarat Emergency Department with a two-day history of increasing shortness of breath. He was found to be in atrial fibrillation.

12. The medical record for this attendance documented that earlier that afternoon, a cigarette had ignited Jeffrey’s home oxygen resulting in facial burns. He was advised to cease smoking. He was reviewed by the Ear Nose and Throat team who documented that he had sustained a small flash burn to the face as a result of the fire, but there were no airway concerns.

2 The State-wide Equipment Program provides subsidised funding towards the cost of assistive technology equipment and related products. SWEP is a business unit of Grampians Health Ballarat and is funded by the Department of Health < https://swep.bhs.org.au/>.

3 The medical record does not identify the supplier.

13. Jeffrey was admitted under the cardiology team for treatment of his atrial fibrillation and discharged the following day on new anticoagulant medication.

14. At around 3:30am on 30 December 2024, Jeffrey went out to the front porch of his home to have a cigarette. He was wearing nasal prongs which were connected by a long tube to a portable oxygen tank inside the house. The evidence suggests that Jeffrey lit his cigarette which in turn ignited the oxygen flowing from the nasal prongs. He fell forward off the porch.

15. Jeffrey was located by his son who immediately called Triple Zero and commenced CPR.

Sadly, he was declared deceased by paramedics at 4:05am.

Identity of the deceased

16. On 30 December 2024, Jeffrey Thomas Wilson, born 1 May 1948, was visually identified by his son, Luke Wilson, who completed a Statement of Identification.

17. Identity is not in dispute and requires no further investigation.

Medical cause of death

18. Forensic Pathologist Dr Melanie Archer from the Victorian Institute of Forensic Medicine (VIFM) conducted an external examination of the body of Jeffrey Wilson on 2 January 2024.

Dr Archer considered the Victoria Police Report of Death (Form 83), post mortem computed tomography (CT) scan, medical records and scene photographs and provided a written report of her findings dated 5 February 2025.

19. The external examination showed charring and soot deposition over the nose and mouth.

20. Toxicological analysis of post mortem samples did not identify the presence of any alcohol or other common drugs or poisons. There was also no detection of significant carboxyhaemoglobin.

21. Dr Archer provided an opinion that the medical cause of death was 1(a) EFFECTS OF FIRE DUE TO HOME OXYGEN IGNITION IN THE SETTING OF SMOKING, 2 LUNG CANCER.

FURTHER INVESTIGATION

22. Home oxygen provides supplemental oxygen to individuals at their home and is delivered by either a portable cylinder or oxygen concentrator. Oxygen therapy has showed to improve survival rates in patients with COPD and hypoxaemia.

23. Home oxygen is contraindicated in patients who smoke because of the risk of fire.

In Depth Case Review

24. An in-depth case review (IDCR) was commissioned by Grampians Health following Jeffrey’s death, and a copy of the IDCR provided to the Court.

25. The IDCR was unable to identify the supplier of Jeffrey’s home oxygen. Oxygen must be prescribed by a medical officer, and a prescription for same was not documented in the medical record. As noted above, SWEP had been consulted but advised that he did not meet eligibility due to Jeffrey’s recent smoking history. The Director of SWEP explained during the review that the service may have previously advised consumers of private oxygen suppliers, but this practice had now changed.

26. The medical progress notes from Grampians Health documented that Jeffrey was willing to cease smoking, and the risks of smoking while on home oxygen were discussed with him.

There was no documentation to suggest that he continued to smoke while an inpatient.

27. The IDCR identified the following learning: There is currently no formal process or guideline to support clinicians when managing patients who require home oxygen therapy that do not meet hospital discharge criteria, including situations where oxygen may need to be retrieved due to safety concerns. This lack of a standardised approach has led to inconsistencies in clinical assessment, follow up care, and risk management, leaving individual clinicians to make complex decisions without structured support.

28. The following recommendations arose from the IDCR:

1. Develop a centralised point of referral for all patients requiring home oxygen, regardless of eligibility for Statewide Equipment Program (SWEP) / Grampians Health (GH) at home, smoking status or other oxygen hazard. Collaborate with private suppliers to ensure the safe and consistent provision of home oxygen services.

2. Create formal guidelines to support clinicians in relation to patients receiving home oxygen on discharge that includes:

• Patient assessment and standardised indication criteria

• Multidisciplinary risk assessment

• Patient education

• Community follow up options including minimum level of aftercare until review at oxygen clinic and transition to SWEP oxygen program

• Provide guidance to clinicians in communicating with local oxygen suppliers to ensure consistent supply, follow up and process for oxygen withdrawal if deemed necessary.

29. The IDCR also acknowledged that two flow charts were implemented in February 2025 to guide care provided to patients who receive home oxygen.

Process changes

30. Grampians Health changed its discharge oxygen process at the beginning of 2025, which Head of Respiratory Medicine Dr Damoon Entesari-Tatafi noted, with hindsight, may have helped in Jeffrey’s case.

31. Patients now discharged on home oxygen are admitted to the Hospital in the Home program (where eligible). They are only eligible if they have been reformed from smoking for longer than six weeks, or after respiratory review for patients reformed less than six weeks. The respiratory physician would exercise their clinical judgment in determining whether a patient is a suitable candidate for home oxygen. This would be supported by patient education, engaging family and carers.

32. In his statement to the Court, Dr Entesari-Tatari detailed the complexities that come with providing home oxygen. He noted that Grampians Health Ballarat had a historical (now ceased) arrangement that SWEP administered hospital discharge oxygen and had strict criteria that funding would only apply when a patient had proven themselves not to be a smoker for a period of six weeks. He considered that this “rigid arrangement” contributed to the use of private suppliers of oxygen.

33. Dr Entesari-Tatafi explained that a difficult situation was created where patients who were stabilised during admission cannot access oxygen therapy, even if they were abstinent in hospital and committed to ongoing abstinence and understanding of the risks. Such a situation creates an environment encouraging a work-around to avoid hospitalisation for six weeks or sending a patient home at risk of deterioration.

34. Dr Entesari-Tatafi opined that judgment was required to balance the risks involved, and these situations require a risk assessment of providing versus withholding oxygen treatment. He was unaware of any guidelines providing clear guidance for hospital discharge oxygen and said that if such guidelines were too paternalistic and prescriptive with regard to risk management, they could risk confining patients to hospital.

COMMENTS Pursuant to section 67(3) of the Act, I make the following comments connected with the death.

1. The issue of prescribing home oxygen to patients who have a history of smoking is a nuanced one. It is a medication that can improve survival and wellbeing and therefore should not be unnecessarily withheld, but it does come with risk.

2. Jeffrey’s admission to hospital on 27 December 2024, where they found him to have burns from the very scenario that caused his death three days later, should have been a warning sign.

This is acknowledged by Dr Entesari-Tatafi, who stated “at this point it would have been prudent to contact the prescribing doctor responsible for the patient’s ongoing care and oxygen provision and in the absence of this requested a respiratory review regarding the appropriateness of ongoing oxygen supply.”

3. That said, there is obviously an element of patient agency at play. Jeffrey was, to my knowledge, a man of sound mind who was independent and able to make decisions regarding his own health. I do not purport to understand Jeffrey’s mindset in choosing to continue to smoke even after sustaining burns three days prior, other than to acknowledge that it must be extremely difficult to be faced with a devastating and short prognosis and suddenly be required to cease a lifelong addiction.

4. Grampians Health’s new discharge home oxygen process, whereby a respiratory consultant would be involved in exercising judgment about a patient’s suitability for home oxygen where they ceased smoking less than six weeks ago, appears to me to be an appropriate and patient centred approach to the issue.

5. Whilst I acknowledge and appreciate the extreme risk that comes with a patient smoking while using home oxygen, I have carefully considered Dr Entesari-Tatari’s views and am not convinced that a policy that categorically denies access to home oxygen based on an arbitrary period of cessation is the optimum way forward.

RECOMMENDATIONS Pursuant to section 72(2) of the Act, I make the following recommendations: i. In the interests of promoting public health and safety and preventing like deaths, I recommend that the Department of Health consider whether a discharge home oxygen process similar to that instituted by Grampians Health, involving Hospital in the Home and specialist respiratory review, be recommended as a model of care to other health services.

FINDINGS AND CONCLUSION

1. Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings: a) the identity of the deceased was Jeffrey Thomas Wilson, born 1 May 1948; b) the death occurred on 30 December 2024 at Unit 3, 1 Glenvale Road, Mount Clear, Victoria 3350; c) I accept and adopt the medical cause of death ascribed by Dr Melanie Archer and I find that Jeffrey Thomas Wilson, a man with lung cancer, died from the effects of fire due to home oxygen ignition caused by smoking;

2. AND, having considered the available evidence, I find that Jeffrey Thomas Wilson’s death from the effects of fire was preventable, though I acknowledge his short prognosis due to natural disease.

I convey my sincere condolences to Jeffrey’s family for their loss.

Pursuant to section 73(1A) of the Act, I order that this finding be published on the Coroners Court of Victoria website in accordance with the rules.

I direct that a copy of this finding be provided to the following: Beverley Wilson, Senior Next of Kin

Department of Health Grampians Health Senior Constable Emma Grantham, Coronial Investigator Signature:

AUDREY JAMIESON CORONER Date: 3 February 2026 NOTE: Under section 83 of the Coroners Act 2008 ('the Act'), a person with sufficient interest in an investigation may appeal to the Trial Division of the Supreme Court against the findings of a coroner in respect of a death after an investigation. An appeal must be made within 6 months after the day on which the determination is made, unless the Supreme Court grants leave to appeal out of time under section 86 of the Act.