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Has a Coroner ever got it wrong...??????

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  • Has a Coroner ever got it wrong...??????

    Got a call today in relation to a very well known case downunder where there was two child fatalities. Was put down to CO poisoning caused by faulty heater. Opinions have been expressed by many but it came down to the "regulator" to carry out the investigation and report to the Coroner. Many believe that the Coroner has got it wrong. I suppose we just want to see if there is any other cases and what the results were.

  • #2
    Re: Has a Coroner ever got it wrong...??????

    I feel the coroner let the owner off the hook he had three chances to have the heater checked for carbon monoxide poisoning but didn`t and two children are dead I just hope the civil case nails him against the wall and costs him heavily

    Tony

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    • #3
      Re: Has a Coroner ever got it wrong...??????

      I dont know about your case but the effects of CO poisoning are very easy to identify in both the living and the dead. It's easy enough for even an HVAC guy to see it in the living when he walks into the customer's house.

      How does it work down there? The coroner runs the investigation rather than a police detective? What is a "regulator"? I can't identify with the term.
      ~~

      ... it was plumbed by Ray Charles and his helper Stevie Wonder

      Comment


      • #4
        Re: Has a Coroner ever got it wrong...??????

        Originally posted by AFM View Post
        I feel the coroner let the owner off the hook he had three chances to have the heater checked for carbon monoxide poisoning but didn`t and two children are dead I just hope the civil case nails him against the wall and costs him heavily

        Tony
        Tony this is where it gets extremely delicate. ESV stuffed around for so long and who were the investigators? what are their qualifications? why did they keep the investigation so quiet/

        There are issues with the home owner and the servicing of the heater but there should also be some responsibility borne by the regulator, ESV, for their failure to support and enforce a regulatory service regime as is in place in the UK. There is a lot of questions that are delicate and have gone unanswered which are aggravating many professional. What has been highlighted is that the new regulatory regime has made ESV virtually powerless when it comes to licensing and enforcement. They can direct the GAs retailer to withdraw supply but it is the Plumbing Industry Commission who is responsible for enforcement and discipline of us as Professionals. We have another USELESS PUBLIC SERVICE BUROCRACY which is doing nothing. When they disbanded the GAs & Fuel they did not embrace the importance and actual powers the old inspectors had. ESV is asleep at the wheel.

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        • #5
          Re: Has a Coroner ever got it wrong...??????

          Punky CO & CO poisoning is commonly misdiagnosed because it wasn't as common as it is becoming. Here we used to have a very good regulator in the Old Gas & Fuel Corporation. We had Gas Inspectors who were licensed Plumbers who came up through the ranks and learned the trade. They were real men who knew what they were talking about and they worked with the tradesmen. None of us were or are perfect but we were all ready to discuss and resolve issues and concerns without confrontation or threats. Don't get me wrong, our Inspectors could be nasty when required but I was fortunate to never experience the bad side. So the G&F was disbanded and we have this institution called Energy Safe Victoria. Now we work under a self certification scheme here and have done so for 15+ years. However the skill set has diminished. The "gotta be cheaper mentality" has progressed and the education gone backwards. Our Apprentices are only interested in money, end of day and facebook. Many will have RSI before they reach 30 due to the constant texting. What we are getting is attention deficit disorder of the worst kind. They don't, and many tradesmen too, focus on the task as a whole. Many can only have one thought at a time. I have worked with 50++++ yr old "plumbers" who cant do two tasks at once. So to get back to ESV. They were supposed to fill the gap under the new system but the way they were set up have failed. They have failed dismally. It is borderline culpable and negligent. They are bullying their way around and their charter is far from being followed. Unfortunately Governments like safe zones and this is what ESV is. They are public servants who are paid huge wages and we question what for. They have never been in the real world and believe everything that they say is gospel.
          Now just to throw in a curve ball they recently recruited some new inspectors. Now we have and always have had a category called TYPE B gasfitting. This is the more complex gasfitting installations generally associated with commercial and industrial installations. Now this can be tricky and is something that you don't learn in a course of a couple of weeks. It takes time and a lot of study as well as in field hands on understanding. So, they hire 4 new inspectors all geared up for being TYPE B Inspectors, going around checking on our work. Big problem, these guys were absolutely useless and knew absolutely nothing. So they send them off to school, couple of weeks and they are now our Regulators.
          So with quasi bunch of experts when this unfortunate CO poisoning occurred the Coroner enlisted this organization to investigate. Now the Coroner would "expect" that she was getting the best of the best but unfortunately there are many out here in reality world who suggest different. The big question is how the Coroner could reach a finding without the incident being repeated. There are many aspects of the incident that don't add up.
          Now being totally respectful of the family as most of us have kids as well and cant for a moment imagine being in that place, just want the truth to come out so we can prevent this happening again. Many think that there should have been better qualified investigators employed to carry out the investigation. ESV sat on their hands for nearly two years with this case and only after extreme pressure from Gasfitters got the Coroner to allow information to be released without prejudicing the Coroners decision. We needed to focus on what could of caused this and work towards greater awareness for all professionals to look out for. Now in the old days we were taught this as part of our apprenticeship but that was lost in the deregulation phase even though the Governments were constantly warned of the potential consequences. Now a recent ESV newsletter is puffing their chests and banging on about educating us. I only hope that the company TPI Instruments reads this because ESV has made some very damaging statements. They also refer to a "procedure" for testing for CO. Again this is a joke.
          Now with apology to all other Professionals here for this quite long post but I have attempted to open up discussion around what many of us believe is a wrong decision. Many think that the Coroner has taken the easy way out to ease the pain of the family as ESV were not capable of replicating and showing exactly what happened. I just wonder whether this is unique or whether others have seen similar happen before. Please understand that all who have discussed this are totally respectful towards the family and suggest nothing inappropriate.
          With ESV and our actual Licensing Authority, what is now known as the Victorian Building Authority, formally known as the Plumbing Industry Commission, there are articles putting them on notice that this would happen. Deregulation has been applauded as streamlining the process and cutting the red-tape with permits and approvals. However it is directly responsible for creating this situation and others similar. I personally wonder what Authorities are like in your areas and how do they regulate the Licensed Gasfitters.

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          • #6
            Re: Has a Coroner ever got it wrong...??????

            That was a informative post Cleanmen 2 why don`t you email it to the Age and Herald Sun letters to the editor as I feel they would be vary interested in it from someone in the trade

            Tony

            Comment


            • #7
              Re: Has a Coroner ever got it wrong...??????

              Sounds to me like a big fat complicated mess!

              In my area, not a large metropolis, we have no licensed gas fitters. I can install any gas appliance and associated piping I feel I am qualified to do. If I could weld (which I can't - I fry things) I would also be legal to do any kind of large gas line.
              ~~

              ... it was plumbed by Ray Charles and his helper Stevie Wonder

              Comment


              • #8
                Re: Has a Coroner ever got it wrong...??????

                No disrespect PUNKY but here we have rules. We have trained gasfitters who are supposed to know what they are doing. However with the demise of the old corporation so too was the start of the death march of knowledge and education. Unfortunately the dregs of the trade were swept up and formed this new Authority now named Energy Safe Victoria. Now we have inspectors who think they know everything yet some of the old guys will tell different. Then we have the career PUBLIC servants who are Teflon coated and wont put their names to anything for fear of failure and being flogged(so what are they supposed to do to earn their salary???????????????). I suggest they are like petty criminals, taking what they haven't earned. Now then there are the Inspectors who run businesses on the side. This is something they are not supposed to do yet a blind eye is turned away and the age-old attitude prevails. Who cares, obviously not those that should. Maybe I am just a dinosaur who is becoming extinct. Is it really wrong to actually care about human life over money. What value do we put on the lives of the young. Don't they deserve the truth to come out and prevent it happening again.

                Comment


                • #9
                  Re: Has a Coroner ever got it wrong...??????

                  Originally posted by Cleanmen2 View Post
                  No disrespect PUNKY but here we have rules. We have trained gasfitters who are supposed to know what they are doing. However with the demise of the old corporation so too was the start of the death march of knowledge and education. Unfortunately the dregs of the trade were swept up and formed this new Authority now named Energy Safe Victoria. Now we have inspectors who think they know everything yet some of the old guys will tell different. Then we have the career PUBLIC servants who are Teflon coated and wont put their names to anything for fear of failure and being flogged(so what are they supposed to do to earn their salary???????????????). I suggest they are like petty criminals, taking what they haven't earned. Now then there are the Inspectors who run businesses on the side. This is something they are not supposed to do yet a blind eye is turned away and the age-old attitude prevails. Who cares, obviously not those that should. Maybe I am just a dinosaur who is becoming extinct. Is it really wrong to actually care about human life over money. What value do we put on the lives of the young. Don't they deserve the truth to come out and prevent it happening again.
                  This is why I started my own company. The other guy cared more about his money than the safety of his customers.

                  I'm sure there are rules elsewhere in my country, probably even in other areas of my state. It doesn't sound like your rules are being followed or enforced. So what's the use of having them? Just sayin'...

                  My town has a part-time 'rent-a-inspector' that is shared by other small municipalities. This inspector hardly knows how to get out his car, let alone inspect a structure, plumbing, heating or gas lines. The gas company here only requires that a 'qualified contractor' install gas lines. They won't define 'qualified contractor', though. "Call your plumber" is the normal answer. While I do what the code says not everyone does. Like your situation, the rules are neither followed or enforced. There's a pants-load of hack work around me. Hack work caused my uncle's garage to explode 2 years ago. The explosion, caused by hack gas guys, leveled the garage, damaged a silo, collapsed part of the barn, and removed the house from its foundation. Pieces of the garage (man doors, roofing, etc) were found half a mile away.
                  ~~

                  ... it was plumbed by Ray Charles and his helper Stevie Wonder

                  Comment


                  • #10
                    Re: Has a Coroner ever got it wrong...??????

                    Read the Coroners findings toady as they are now available on the web site. If anyone is interested. And they have the audacity to rubbish us for caring and suggesting that you actually should use a professional. You be the judge

                    Finding - 203810 Tyler Robinson - Coroners Court of Victoria

                    Comment


                    • #11
                      Re: Has a Coroner ever got it wrong...??????

                      It has come to my attention that the Coroner may have n=been reading this forum and others. It has been suggested that the Coroner is extremely worried that she has ben misled by the incompetence of a Government Regulator with limited skillset. This unfortunate incident will not bring back the two boys but the arrogance of these Public Servants in covering up their incompetence will soon be made public. Energy Safe Victoria is only interested in covering up and saying nothing. They are Public Servants who are only looking at the size of their retirement packages and nothing else. There is a huge amount of evidence that is going to be handed over to the Newspapers.
                      I don't know what level of gas regulators and regulations you guys work to or under. I question whether they work under a scheme whereby "it takes three people to die in a season" to trigger an investigation. This is the most disgusting part of this Public Servant Organisation/Department. They actually base their investigations on the number of people who die.
                      I have raised this issue here hopefully so that many will read and see how disgraceful a supposed Regulator is. they have employed ex-policemen as Investigators but they have absolutely no skill-set whatsoever. They treat Licensed Plumber Gasfitters as petty criminals. Yes this is a one-sided post but if Energy Safe Victoria was to come out and challenge this one would see that the truth is the only defense. Why did these two young boys die?????
                      Why wont they come out and talk about it???? How many more will die because of the incompetence of the Regulators?????

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