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1976 to 2008 - Outside World

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Minus Children Appeal

The nine residents who perished on 8 April 1996.jpg

1996 Kew Fire

On the evening of 8 April 1996, a fire occurred in Flat E, Unit 31 of Building 37 at Kew Residential Services (KRS), Kew. Tragically, the fire took the lives of nine intellectually disabled residents. Kew Residential Services is operated by an agency of the Victorian Government, the Department of Human Services, and accommodates approximately 600 intellectually disabled persons. The fire detection and protection system at KRS has been the subject of continued criticism and concern over several decades. During that time a number of governments and their agencies have been responsible for the residents at Kew. The one constant is that such residents should be protected from the devastating effects of the fire by the State of Victoria, and that that protection should have been in place to prevent the tragic events of 8 April 1996.



  1. The State of Victoria owed a duty of care to the staff and the nine intellectually disabled residents at Kew Residential Services. 

  2. For ten years (since 1986), the State of Victoria had been given warning after warning by consultants, experts, personnel and different government instrumentalities as to the inadequacy of the fire safety system at Kew Residential Services.

  3. These warnings had been given to the State of Victoria over the period of several governments and departmental agencies having responsibilities for fire safety at Kew Residential Services.

  4. The present government and the Department of Human Services had made substantial efforts to upgrade significantly the fire safety systems at Kew Residential Services.

  5. However, the fact remains that ten years is far too long for the State of Victoria to have got its house in order, particularly when considering the life and safety of the persons to which it owed a duty of care.

  6. The State of Victoria has contributed to the fire and deaths of the nine residents because, despite all warnings it had received over the decade from 1986, no proper fire safety system was in place at the time of the fire. 

  7. This is not the only way in which the State of Victoria has contributed to the deaths. These other ways are detailed in the findings.

  8. The role of various consultants and contractors was comprehensively investigated during the inquest, and a number of shortcomings, areas of criticism and scope for improvement have been identified; however, on the recognised legal standard, those parties have not contributed to the deaths.

  9. Nonetheless, it is encouraging that the State of Victoria was undertaking substantial efforts towards a proper fire safety upgrade at the time of the fire. In addition, during the currency of the inquest, the State has made several positive moves towards improving fire safety. The commitment of $75.5 million to ‘continue the program of fire safety audits and works’ in Department of Human Services facilities is a particularly positive step. The extent of the positive work towards improving fire safety along with the implementation of the many recommendations will, no doubt, significantly reduce the chance of such an event recurring.

  10. Throughout the inquest, the importance of learning from the fire so that the same errors will not occur again has been stressed. The positive lessons learnt from the investigation of the fire will have consequences for other governmental and private institutions that look after intellectually or otherwise disabled persons. 

  11. The Kew Residential Services fire remains a tragedy for the State of Victoria and, in particular, for the victims and their families.

Graeme Johnstone, Inquest Findings, Comments and Recommendations into Fire and Nine Deaths at Kew Residential Services on 8 April 1996.
Melbourne, State Coroner's Office, 1997, page 10.

Great concern

Community Visitors have often found their visits at the KRS site to be quite frustrating and even distressing during the past twelve months for the following reasons:

  • It is being regularly reported that poor practices that were seen when the Community Visitor Program first began, are returning and/or increasing (refer to Basic Hygiene).

  • The availability, consistency and ability of staff who are skilled enough to provide innovative and enthusiastic support to the residents who remain on site is of great concern. This has consistently been raised with management throughout the past year (refer to Care Provided).

  • A return to child-like language when talking to adult residents and a return to familiar institutional practices like the use of protective clothing when interacting with residents.


It is frustrating for Community Visitors to have to report on such issues on so many of the visits and to see the increase in poor practices that had previously been substantially reduced. It is distressing that such an inadequate standard of support is provided to these people.


Community Visitors are extremely concerned that the quality of care for those residents waiting to move from KRS to the community will continue to deteriorate progressively over the time taken for the redevelopment.

Excerpt from the Annual Report, 2002/03, Community Visitors, Intellectually Disabled Persons' Services Act 1986; Disability Services Act 1981.

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