Coroners Court inquest into the death of Sonia Sofianopoulos

On 22 August 2018, Coroner Hawkins handed down her eight recommendations after conducting an inquiry into the tragic death of Ms Sonia Sofianopoulos. The Coroner found that the death of Ms Sofianopoulos was a result of carbon monoxide poisoning, caused by “a confluence of events that proved to be fatal”.

Victorian Government response

On 18 October 2018, the Victorian Government released its response to the Coroner’s recommendations. The Victorian Government offers its sincere condolences to the family and friends of Ms Sofianopoulos and supports or supports in principle all eight of the Coroner’s recommendations. The full Government Response can be found here (PDF and word).

Implementation progress

The Victorian Government is taking steps to implement the Coroner’s recommendations and additional actions to improve public health and safety.

In response to the Coroner’s recommendations, the Victorian Government supported-in-principle the recommendation to consider a phase out of open flued gas space heaters through a regulatory impact statement (RIS) process.

The RIS is available on the Engage Victoria website and was open for public consultation from 29 December 2020 to 22 February 2021. The RIS identifies the costs and benefits of different options for phasing out open flued gas space heaters in accordance with the Coroner’s recommendation. Following detailed consideration of all submissions, the preferred approach to phase out open flued gas space heaters through fast-tracked Australian Standards will be implemented. A Gas Technical Regulators Committee Technical Guidance Bulletin, published on 19 May 2021, requires open flued gas space heaters adopt stringent new safety requirements by 1 January 2022.

Your safety is our priority

The safety of Victorians is the Government’s first priority. The Government is acting in response to the Coroner’s recommendations to deliver strengthened safeguards for Victorians.

Victorian Government response: summary



1. Phase out open flue gas space heaters Support-in-principle The Department of Environment, Land Water and Planning (DELWP) has undertaken a review of open flued gas heaters and a Regulatory Impact Statement (RIS) process to consider phase out options. In progress
2. Mandatory continuous professional development for plumbers Support DELWP is developing a continuing professional development (CPD) scheme for registered and licensed plumbers (including gasfitters) to assist them in keeping up to date with latest developments in technology relating to their profession. The scheme is expected to be introduced through new regulations in 2021. In progress
3. Climate Technologies to publish articles warning of the importance of servicing Support Climate Technologies to publish advertisements in The Herald Sun and The Age on 2 October 2018. Complete
4. Energy Safe Victoria (ESV) to publish an article in their quarterly newsletter on CO spillage testing Support ESV published articles about the importance of carbon monoxide spillage testing and guidance material on equipment in the Energy Safe Magazine Winter 2018 edition and in each of its quarterly newsletters since the release of the Coroner’s report. Complete
5. The Victorian Building Authority (VBA) to review requirements for certificates of compliance Support The VBA has undertaken an assessment of issues associated with the provision of compliance certificates for servicing, testing and maintenance of open flued gas heaters. That assessment identified four possible options for improvements.

Introduction of some the four options may require legislative amendments. DELWP will work closely with the VBA to finalise options and lead any policy work necessary to support change.
In progress
6. Chairman of Australian Standards Committee to consider adding Appendix R of AS/NZ 5601 Support The Standards Australia – Committee Responsible for Australian Standard: 4575 Gas Appliances – Quality of Servicing has approved the amended standard AS 4575 and published it on 9 August 2019. Complete
7. ESV to review communication of guidelines, changes and updates Support ESV has commenced a research project to review its communications approach to all stakeholders and a program to restructure its website to improve communication through the site.

To ensure communications are wide‑reaching ESV has developed communications on gas heater safety across multiple formats including: information sheets, social media posts and newspaper advertising.
In progress
8. Media and public awareness campaign on open flue heaters Support ESV ran the ‘Be Sure’ carbon monoxide awareness campaign over winter 2019 and winter 2020. The campaign encourages Victorians to take action and get their gas heaters serviced by a qualified gasfitter at least once every two years.

The Victorian Government provided $1.7 million for the campaign to run over winter 2019 and winter 2020.

Page last updated: 13/07/21