Process failures leave mystery for Lismore house fire case
"Inadequacies" in a post-mortem examination and "missed opportunities" in the investigation following the death of a Lismore man 20 years ago have led to lasting mystery surrounding the incident.
Peter Allen would have turned 64 last week, the day before Deputy State Coroner Derek Lee handed down his findings following an inquest into his death.
Firefighters and police attended Mr Allen's home on Avondale Ave in Lismore about 4.50am on Sunday, November 26, 2000.
The home was well alight and after the blaze was extinguished, Mr Allen's body was found inside.
He was known to be a heavy smoker and his wife, living away at the time due to a health issue, had previously expressed concerns about the risk of him falling asleep with a lit cigarette, the inquest heard.
Investigators who attended the scene could not identify a direct ignition source but attributed the fire to an electrical fault "despite there being an absence of any physical evidence confirming that this was the case", Mr Lee said.
Dr Geoffrey Cawley, who conducted the post-mortem, found no signs of violence and found Mr Allan's death was accidental, by way of fire-related injuries.
But Mr Lee has found the cause and manner of death could not be clearly determined.
An earlier inquest was dispensed with in June, 2002, but four years later, police received reports the fire may have been deliberately lit, and the death may have been a homicide.
Matthew Walker was waiting for sentence on an unrelated matter when he claimed a fellow inmate, Andrew Benn, had made admissions to being involved in the incident.
Mr Benn was charged with murder, malicious damage, break-and-enter and larceny in February, 2007 but all except the larceny charge - which he pleaded guilty to - were later withdrawn.
The allegations had centred around claims a robbery and assault upon Mr Allan preceded the fire, the inquest heard.
One expert, Dr Linda Iles found the autopsy exam was inadequate in terms of determining whether Mr Allen died before or after the fire, or identifying his cause of death, the inquest heard.
The inquest heard there had been changes to post-mortem processes in fire-related deaths in 2002.
Mr Lee said he was unable, through the inquest, to know whether autopsy standards or NSW Health policies relevant to this case applied at the time of Mr Allen's death.
But two professional opinions expressed to the inquest found the exam "was not conducted in accordance with the professional standards for the examination of fire-related deaths at the time".
"Critically, routine examinations expected to be performed in the context of a fire-related death were not, in fact, performed," Mr Lee said.
He found an investigator "relied heavily" on the results of that flawed post-mortem exam and the inquest heard original investigation file could not be located.
He said it was important to note there had been "significant improvements" in post-mortem processes, both generally and specifically for fire-related deaths, since November 2000.
"Current procedures and guidelines now provide a more robust and comprehensive system for the post-mortem examination of such deaths," Mr Lee said.
He said "more robust practices regarding fire investigation" had also been implemented in the decades since the incident.
Mr Lee said Mr Allan was remembered by his love ones as a "true nature lover and keen gardener".
"It is evident Peter enjoyed a loving relationship with his family members and that, 20 years after his passing, he is still greatly missed," he said.