Details of a house fire in Onehunga where a 6-year-old girl perished and her six siblings survived have been revealed by the Coroner.
The fire was started by a preschooler playing with matches in an upstairs bedroom.
When he was caught, the fire already alight, he said "I did the fire".
Anaseini Sarah Hadessa Ma'asi died in a fire at her Oranga Ave home in Onehunga on November 25, 2013.
The fire started at about 4pm in the second storey of the house.
Anaseini was at home with her mother Amelia Ma'asi and six of her siblings at the time.
Coroner Morag McDowell revealed today in findings released following an inquest that the fire started after another child in the house was playing with matches.
The findings outlined the last minutes of Anaseini's life.
McDowell said the fire started in a bedroom upstairs at the address.
"On realising there was a fire... Mrs Ma'asi yelled to her children to leave the house and to meet at the big tree on the front lawn," McDowell stated in her findings.
"Emergency services were called. Mrs Ma'asi also made efforts with her oldest son to get a hose to fight the fire. She realised then that her 6-year-old daughter Anaseini was still inside, in a bedroom on the second floor.
"Mrs Ma'asi and two of her neighbours attempted to get to the second floor but were unable to do so because of thick smoke."
Soon after firefighters arrived they found the little girl behind a door in an upstairs bedroom, unconscious.
Attempts to revive her were unsuccessful and she was pronounced dead at the scene.
A post-mortem examination revealed that Anaseini died as a result of inhaling toxic fumes.
In her findings McDowell revealed how and why the fire started.
She said Anaseini lived at the Housing New Zealand property with her parents and six siblings - who have all been granted permanent name suppression - aged between 2 and 12.
The day she died all of the children were home from school as a number of them were on antibiotics for boils.
Anaseini was not ill, but was considered too young to make her own way to school and with sick children her parents could not take her.
During the day she and her siblings played in and outside the house.
At 4pm Mrs Ma'asi and her eldest son heard an alarm going off.
She did not realise it was the smoke alarm at first - it sounded similar to her washing machine - and she asked her son to go and find out where the noise was coming from.
"(He) realised the noise was coming from upstairs and went to investigate. It was coming from the boys' bedroom," McDowell said.
"On entering the bedroom he saw his (younger) brother holding a match and matchbox."
The boy looked at his brother and said: "Fire. I did the fire."
The older child saw a pillow on fire and told his sibling to go downstairs, to get out.
"(The eldest child) made a brave attempt to pick up the pillow, thinking to throw it outside, but it was too hot," McDowell said.
"He then raise the alarm with his mother - who yelled for the other children to leave the house and called emergency services.
"(The eldest child) also got some jugs of water and tried to return upstairs but was driven back by thick black smoke."
He and Mrs Ma'asi ran to get the hose and at that point, realised Anaseini was not outside with her siblings - she was still inside the burning house.
Neighbours came to help and two went back into the house with Mrs Ma'asi and tried to get up the stairs.
"They could not get into the girls' room, where they believed Anaseini to be, because the smoke was too thick. They had to retreat outside," McDowell outlined in her findings.
When firefighters arrived they quickly began a search of the house.
Nicholas Durose approached the girls' room with a colleague and opened the door.
Thick black smoke poured out and there was zero visibility.
"He reached behind the door and felt Anaseini's legs," McDowell stated.
"She was on the floor with her head towards the bed . . . Durose managed to pull Anaseini out of the room whereupon she was taken outside and attempts were made to revive her."
The fire was extinguished but the little girl did not survive.
The fire investigation
The Fire Service carried out a full investigation into the fire and the report was presented to McDowell.
A scene examination showed that there were smoke alarms in the house.
There were two in a kitchen drawer and one activated during the blaze; another in the lounge which was faulty even though it had a new battery; one in the girls' bedroom which was too deformed from the fire to be tested and one in the boys' bedroom which activated.
There was an additional smoke alarm bracket in the dining room but the alarm had been removed.
The report stated that the majority of the fire, smoke and heat damaged was contained to the upstairs stairway, bathroom and both bedrooms.
The boys' bedroom had extensive charring and burn patterns showed the fire started there.
In that bedroom fire investigators also found 74 burnt and unburnt matches.
McDowell said after the investigators took into account the forensic evidence at the scene and the eldest child's evidence it was concluded that the fire "was the result of a child playing with matches".
"Other causes, for example, relating to electrical issues, heaters, fire and smoking, were excluded," she said.
Fire safety programme rejected
The fire investigators also revealed in the report to the Coroner that the playcentre where the child who lit the fire attended had been offered a fire-wise education programme before Anaseini's death.
"This offer had not been accepted,' McDowell said in her findings.
"However a fire-wise DVD located on the floor of the boys' room indicated that at least one of the older children had some introduction to the school programmes on fire safety."
Child's access to matches "a real concern"
McDowell said it was "self-evident" that the child who lit the fire "does not have the capacity to fully appreciate the risks associated with lighting matches".
"No blame can be attributed to that child," she said.
"Rather, the real concern is that he had access to matches."
McDowell revealed that Ma'asi gave evidence during the inquest and said she had previously caught the child who started the fatal fire with a lighter.
She "told him off" on November 6 - the day after Guy Fawkes - when she caught him attempting to use a lighter and warned him that what he was doing was dangerous.
"The lighter is used to light the gas oven in the kitchen and, according to Mrs Ma'asi, was kept on the shelf to the left of the oven," said McDowell.
The mother also told the Coroner that her husband had purchased two or three boxes of matches a couple of weeks before the fire, and they were also kept on the shelf.
"Mrs Ma'asi further stated that after the fire the boys told her that they had lit a candle in their room several days before this incident," the findings reveal.
The eldest child further admitted that a few weeks before the fire another of his brothers had been lighting matches in their bedroom, that there were burnt matches scattered around and that the sibling who lit the fire that killed Anaseini "told him that he had got the matches out of a drawer" in the boys' room.
Anaseini's father Mulikiha'amea told the inquest that as parents, he and his wife had always told the children "not to play with matches and that only the oldest boys had used matches to light the fire".
McDowell said it was obvious from the scene that matches were accessible to the children.
Alongside the 74 matches found in the boys' room, a further 127 were located in the back yard.
"That matches were so readily found sadly demonstrates that there was a lack of vigilance in ensuring that matches were not accessible to the children," said McDowell.
"There is an obviously an inherent risk associated with young children having access to matches.
"Responsibility for reducing risk rests with parents/caregivers who need to be careful to ensure that young children cannot access them.
"The sad fact of this case is that, but for the children's access to the matches, this fire would not have occurred. The fire and Anaseini's death were entirely preventable."
Housing New Zealand's inspection
McDowell said Housing New Zealand inspected the property in January and June 2013.
An inspection had been scheduled for July but the Ma'asi family were not home so HNZ staff could not access the property.
The inspection was not rescheduled.
Under the HNZ smoke alarm policy the house should have had four smoke alarms - one in the living room, hallway and two upstairs bedrooms.
After the June inspection it was noted that there was no functioning alarm on the ground level of the house but there was one in the hallway.
At the time of the fire that hallway alarm had been removed.
McDowell said there was no mandatory requirement at the time for HNZ to install alarms but it had done so voluntarily as a "responsible landlord in the interests of tenant safety".
She found that the alarms HNZ had installed were "not appropriately positioned" and did not adhere with their own policy - however had this happened it was unlikely to have made a difference to Anaseini's death.
She said it would have provided the child with "only seconds - that is, less than one minute - of additional warning time".
"It is simply not possible to conclude with any degree of certainty whether Anaseini would have escaped the fire with the additional warning time," she said.
What the Coroner recommended
McDowell said since the fire HNZ had responded "swiftly" to recommendations from the Fire Service.
However she believed there needed to be "consistent guidance" on the appropriate placement of smoke alarms for the public - especially since it was now mandatory under the new Residential Tenancies Regulations 2016 for smoke alarms to be installed in tenanted properties.
She said Anaseini's death was a "timely reminder" about fire safety and children.
"To comment that matches and other fire lighting devices and children do not mix, and that caregivers, parents and home occupiers need to be vigilant to ensure that children cannot access such items may be regarded as a statement of the obvious.
"However, the obvious is often worth repeating as basic safety messages are sometimes overlooked while other, more topical issues gain attention.
"A tragic event such as this serves as a timely reminder that sometimes it is necessary to reiterate even the most basic of safety messages."
McDowell said it was perhaps time for consideration to be given to a public safety campaign reminding people about the importance of the safe storage of fire-lighting devices and keeping them out of reach of young children.
At the end of her findings McDowell acknowledged and commended the "courageous actions" of Ma'asi and her oldest child for their "valiant efforts to put out the fire and retrieve Anaseini".