The mother of an Otago boy who died from carbon monoxide poisoning in a shower has told a coronial inquest she will never think of his death as an accident because it was preventable.
By Katie Todd of RNZ
Jesse Samuel, 12, died at his family's bach in Haast in October 2018.
At an inquest in Queenstown, coroner Mary-Anne Borrowdale is examining what she calls the "plainly unlawful" circumstances of Jesse's death and what could be done to prevent something similar happening in future.
Jesse's mother Justine Walker told the court her son had his whole life ahead of him and it had been eight long years waiting for the inquest.
"I know today will never give Jesse his life back, his future, his dreams, his goals. It will not give me my life back and it will not give my children their childhood or their lives back but from today, I wish those involved are made accountable and acknowledged and that changes are made," she said.
Walker described her son as a dedicated athlete, a fabulous big brother and a truly caring soul.
"What I admire most about him was his passion for life. He never missed a moment or an opportunity. He was going to make the most of everything and give it his all," she said.
The inquest follows the 2021 sentencing of gasfitter Michael Cartwright and the company Laser Plumbing Alexandra who pleaded guilty to charges under the Plumbers, Gasfitters and Drainlayers Act.
Cartwright signed off on his co-worker Gary Hale's installation of the water heater despite never seeing the work.
Cartwright and the company were fined more than $120,000.
Borrowdale said Jesse died on a freezing, wet day when the bathroom window was "understandably closed".
The heater was not meant to be used in a bathroom, she said.
"When Jesse showered, the little shower unit filled with carbon monoxide gas. Carbon monoxide is odourless, colourless and tasteless, but it is deadly poisonous," she said.
"When Jesse was found he was unable to be revived."
A 'rudimentary error'
Borrowdale said the inquest would focus on the certification of the appliance, the sufficiency of current training for gasfitters and the regulatory systems in place to prevent dangerous installations.
Gasfitting expert David Whitfield told the inquest that Cartwright made a "rudimentary error" signing a safety certificate for the work.
He said supervising gasfitters were not required to visit every single site but Hale and Cartwright were both working at the Haast property.
Whitfield said Cartwright did not perform any tests or ask Hale for the specifics of what he had done.
The wrong type of ventilation – a flue pipe – was used, while a label on the gas heater showed that it should not be installed in a bedroom, bathroom, toilet or sleeping area, Whitfield said.
He told the inquest it was likely that Hale saw the safety warnings on the gas heater but was not fully aware of the risk.
It had been a long time since Hale was trained, Whitfield noted.
"A person who only does gas burning work infrequently can over time forget some of the fundamental knowledge of the specific regulation or specific part of the standards," he said.
"In my experience, it is common for gas burners to make mistakes if they gas burn as a small percentage of their work."
Whitfield said gasfitters should be required to upload photos and test results of their work to a database.
Such a system would allow regulators to identify and fix dangerous installations before anyone came to harm, he said.
Whitfield said the licensing board – the Plumbers, Gasfitters, and Drainlayers Board – should also have "more teeth" and be allowed to force gasfitters to undertake competency reviews.
The coroner is also expected to hear from Michael Cartwright, Jesse's uncle Brendan Walker, and representatives from WorkSafe, the heating appliance maker Bosch, and the Ministry of Business Innovation and Employment.
The inquest is set down for five days.
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