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WARNING: This story contains graphic and sensitive content.
A distraught mother has spoken of the “hole in her world” after her son died in a tragic fire caused by lighting a cigarette while living in a care facility.
Adam Duncan, 29, died in “very traumatic circumstances”, a coroner has found, but stopped short of making recommendations to prevent future deaths in similar circumstances after the care facility introduced its own changes, including mandatory supervision of smoking residents and buzzer alerts.
Duncan battled Huntington’s disease - an inherited progressive brain disorder that had already claimed the lives of his father, grandfather, and aunt - and suffered burns to a third of his body, passing away from his injuries in Christchurch Hospital two days after the January 2017 accident.
His mother, Pauline Roberts and her partner, Russell, told the Herald the coronial process looking at their son’s death took “a hell of a long time” and noted, “the pain doesn’t leave until the book is closed”.
Roberts said the experience had been hard on the whole family.
The coroner’s report details included that Duncan lived in a flat at Te Ruru in Christchurch.
“I just miss him, his humour and talking - it’s really hard without him,” she said.
“He was our legend in our family, a hero. For him to struggle [with Huntington’s] for so long and stay above water, then go under the way he did was a nightmare. But we have to live with it.”
The coroner’s report, released yesterday, tells how Duncan lived in a flat at Te Ruru, which is operated by New Zealand Care Group Limited, on Woodham Rd in Linwood, Christchurch.
He was diagnosed with Huntington’s disease at the age of 13 but had experienced its symptoms since the age of 10 - which the coroner said was unusually young for the illness to present.
Since 2007, Duncan had moved between care facilities before moving into Te Ruru in 2012 where he was the youngest of nine residents.
Behavioural issues meant he was moved from the main house to a self-contained flat where he was considered to be living “very independently”.
He was described by the coroner as a man with “a big heart”. He enjoyed fishing, gardening, and photography, while also writing Christmas cards for bank staff and people who served him at McDonalds.
Adam had lost his grandfather, father and aunt to Huntington's Disease.
Duncan raised money for a sick family member and a staff member’s village in Africa, the coroner said he did his best not to let his illness dampen his life experiences.
Roberts told the Herald it took an impressive level of strength to stay positive as his illness began to worsen.
“You’re an active young boy, growing into a man and you lose things piece by piece - it takes a strong character to get through that,” she said.
On the morning of the accident, one worker heard an alarm go off, whilst another heard a humming sound.
Both went to investigate. They found Duncan walking down a hallway in flames from his waist up. He appeared to be wearing pyjamas and had a cigarette in his mouth.
One staff member rushed him to a bathroom and washed Duncan down with cold water. He was conscious when emergency services arrived to take him to the hospital.
He was placed in an induced coma for two days. It was then determined between the hospital and Duncan’s family that ongoing treatment “would not be Mr Duncan’s overall best interest”.
Duncan passed away on January 30, 2017 while in palliative care.
Fire and Emergency concluded the source of the fire came from Duncan’s lighter, which he’d used to light a cigarette that morning.
He was a smoker before moving into Te Ruru. Roberts told the coroner of her son’s “dangerous habit” of pulling his jersey from the neck and lighting his smoke underneath it.
The report included a diary entry from staff on the day of the accident which stated: “[No] unsupervised smoking – people must have a staff present when having a cigarette to minimise [the] risk of fire”.
Adam was described by the coroner as a man with “a big heart”, he wrote Christmas cards for bank staff and people who served him at McDonalds.
Back in 2016, according to the report, Roberts mentioned to a Te Ruru staff member she’d noticed Duncan had been dropping more cigarettes than usual and would now supervise him when he was at their home.
She told the coroner the staffer acknowledged her comment but nothing further happened.
The coroner concluded there was enough information available to NZ Care prior to Duncan’s death to suggest they “ought to have reviewed his smoking through a safety-risk lens”.
The coroner outlined the changes made by NZ Care Group at its facilities following Duncan’s death, starting with a nationwide risk assessment of all its patients who smoked.
Smokers at Te Ruru are now only permitted to smoke in designated smoking areas and support workers must supervise. Meanwhile, the facility’s fire alarms now contact Fire and Emergency directly and assist buttons were installed in all flats.
According to the coroner, the chance of a similar incident occurring at the facility is now “significantly mitigated” by the steps put in place.
