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 Mrs Sonia Sofianopoulos. The Coroner found that the death of Mrs 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 Mrs 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 update

The Victorian Government is taking steps to implement the Coroner’s recommendations and additional actions to improve public health and safety. A progress update one year on from the release of the Government Response is available here (PDF and word).

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

RECOMMENDATIONRESPONSE

KEY ACTIONS

STATUS
1. Phase out open flue gas space heaters Support-in-principle The Department of Environment, Land Water and Planning (DELWP) has commenced the review of open flued gas heaters and the Regulatory Impact Statement (RIS) process to consider phase out options, which is expected to be complete by mid 2020. In progress
2. Mandatory continuous professional development for plumbers Support DELWP is developing a continuing professional development (CPD) scheme for registered builders and licensed and registered plumbers to be introduced through new regulations by 2021, following a RIS and formal consultation in 2020. 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 is commencing 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 in winter 2019 were wide‑reaching ESV 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 launched the ‘Be Sure’ campaign to coincide with the beginning of Carbon Monoxide Awareness Week (29 April – 4 May) and issued a media release on 25 April 2019.

In the State Budget 2019-20, the Victorian Government committed a further $1.7 million to increase the reach of the ‘Be Sure’ campaign.

The 2019 campaign concluded at the end of August 2019 and the campaign will recommence for the 2020 winter.
In progress

Page last updated: 25/10/19