Housing harms and the promise of preventive maintenance

Abstract

Despite community expectations that housing provides shelter and safety to its inhabitants, inadequate housing is also a significant social determinant of death. This article examines reports by the Northern Territory Coroner in terms of the systemic and individual factors contributing to deaths caused by housing. These reports highlight the maintenance work instigated by preventable deaths and the need for greater investment in preventive housing maintenance. The article concludes by reflecting on the coronial archive as an object for further examination of housing harms.

Warning: This article considers the deaths of Indigenous persons, and the author warns that readers may find it distressing. ¹

On 28 October 2020, 11-year-old Gunbalanya resident Brody Roy Wauchope-Dirdi, ‘Rory’, was dropped at his uncle’s house to retrieve a phone and play video games. The house was typical of Northern Territory (NT) remote communities: single-storey blockwork on slab construction with verandas on two sides, one of which was enclosed by wire mesh extending upwards to a steel beam. No-one was home when Rory arrived, and he was discovered the following morning by his aunty, hanging immobile across a steel beam.

The forensic pathologist’s initial view was that Rory died of positional asphyxia. ² However, when Rory’s older brother returned to the community five days later and climbed the mesh, he received a shock that temporarily immobilised his neck. An electrician was called who then discovered 240 volts of electricity running through the metal roof. Inspection of the property subsequently found that the insulation on the service conductors (service lines) was badly degraded by exposure to sunlight. In addition, the service conductors and insulated collar were incorrectly installed such that contact was made with braided cables and the metal gooseneck riser attached to the premises. ³ Both the riser pole and the metal roof should have been earthed but were not. The fault causing the live roof ‘may have occurred months or even years ago’. ⁴

Multiple parties must meet legal obligations to ensure safe housing, and the infrastructural failures described in the coronial report for this case highlight the contiguous jurisdictions of distinct authorities charged with servicing remote community housing. The NT government-owned Power and Water Corporation (PAWC) is responsible for power supply and infrastructure to the riser pole, via the Electricity Reform Act 2000 (NT), while the property owner is responsible for electrical infrastructure beyond the riser pole. At Gunbalanya, as at other NT remote communities, leasing arrangements establish the NT CEO (Housing) as landlord, obliged to meet habitability standards under the Residential Tenancies Act 1999 (NT) relating to safety and security. Demed Aboriginal Corporation was contracted by the NT government to deliver remote housing maintenance services at Gunbalanya housing, including electrical installation. The coronial report described that PAWC had no records of the premises’ connection to the electrical network, no Certificate of Compliance, and no records of inspections of the cables and connections over a 25-year period. Similarly, Demed, and other relevant authorities, had ‘no records as to … who undertook the electrical installation and what, if any, maintenance has been undertaken to the premises prior to 2018.’ ⁵

Safe housing requires collaboration among parties with intersecting legal and service responsibilities. Coronial reports focused on housing deaths expose that, instead, the presence of multiple parties allows for the diffusion of responsibility. Mistakes have been made by all parties; therefore, everyone is responsible for the confluence of hardware failures causing a death; therefore, no one person or entity is singularly culpable: the system is responsible. Preventive maintenance is consistently proffered in coronial reports as a programmatic response to such systemic failure – ‘It is likely that an inspection and maintenance regime would have prevented Rory’s death’. ⁶ Preventive maintenance is conceptualised as insurance against the failure of individuals to remedy disrepair, and in recognition of housing’s entropic tendency.

This article builds on research addressing the governance regimes required to deliver and maintain health-conferring housing in NT remote communities. ⁷ Public health research has developed a deep evidence base to demonstrate the importance of functional housing for residents’ health and wellbeing, ⁸ and the contributing impacts of inadequate housing on acute infections and chronic non-communicable diseases are well-documented. ⁹ However, less attention has been paid to how the systems charged with ensuring habitable housing contribute to housing’s disrepair and its associated harms. Coronial reports provide an archive for explicating settler-colonial government systems and processes ‘that otherwise may be hidden from external scrutiny’ ¹⁰ and for understanding the confluence of factors that produce unsafe housing. ¹¹

The following discussion draws on close readings of three coronial reports in which housing hardware failures resulted in residents’ deaths. ¹² These reports illuminate how issues of service jurisdiction, record keeping, and complaints processes contribute to deadly housing. As documentary representations of the coroner’s inquisitorial prerogative and broad jurisdiction, coronial reports constitute a public archive that has been under-utilised in the analysis of housing policy, providing contextual detail about how housing comes to be harmful, including the interaction between systematic failures and bureaucratic or practical incompetence. ¹³ In line with social housing’s fragmented governance, coronial reports illuminate the tussle between the determination of what caused a death and various parties’ attempts to avoid responsibility for it. ¹⁴ Further, coronial reports provide accounts of the responses undertaken to remedy public health and safety issues, following a death and in anticipation of the inquest. ¹⁵ The selected coronial reports provide a history of preventive maintenance for NT remote housing, as typically enacted in a reactive and partial fashion in response to housing-related deaths. The conclusion reflects on how different starting points, via other coronial reports, could generate alternative accounts of housing harms.

The necessity and limit of maintenance records

Reports by the NT Coroner demonstrate a consistent failure by governments and subcontracted organisations to maintain reliable records of house condition. A maintenance record will not prevent a roof electrifying, however it does provide an index of prior work and is one means of encouraging ongoing attention. ¹⁶ In systems for ensuring safe housing where responsibilities are distributed, and where individuals in positions of responsibility change over time (all systems), the record provides a documentary history setting social expectations for ongoing actions and informing new approaches. In the absence of records, there is less assurance that the quotidian operations of maintenance professionals and their contract superintendents will meet legal obligations. Past practices will be less apparent to new subcontracted organisations or employees, and there is an increased likelihood that maintenance becomes vulnerable to conventional approaches deemed ‘good enough’ or ‘what we’ve always (not) done’.

As in Rory’s death, the failure of responsible parties to inspect housing infrastructure and rectify known faults is evident in the coronial report for seven-year-old Tennant Creek resident, Monica Presley, who died by electrocution on 6 March 2005. ¹⁷ Outside Monica’s public housing unit in the Blain St public housing complex, the metal frame supporting the unit’s evaporative air conditioner (EAC) was live with 221 volts of electricity as a result of three discrete faults. The motor had failed, the rubber mount supporting the motor had burned away (creating a short circuit), and the earth lug had corroded and broken free, leaving the unit without earth protection.

Monica was playing with other children and went behind the unit to a garden tap next to the EAC stand. She was discovered unresponsive by a neighbour shortly after. Following Monica’s death, evidence and a report by an electrical safety officer characterised the EAC motor as in ‘very bad condition’ and as a ‘very visible fault’, noting that anyone who removed the pads or turned off the isolator switch – required for any maintenance job – ‘would have had a good view of the motor’. ¹⁸

Monica’s electrocution was not the first indication of problems with this EAC. Her aunty, Marie Louise Murphy, the head tenant of Flat 13, had consistently made complaints that it was not working across the three months prior. Murphy gave evidence that ‘when I go to housing and try to report that air con not working and some people just ignoring me, just because I’m Aboriginal lady’. ¹⁹ A faxed note to the contractor from a tenancy officer responding to one such report stated that ‘the tenant has been in hospital and reckons the air con is not working’. ²⁰ The ‘reckons’ in the communication exemplifies the governmental suspicion applied to Aboriginal social housing tenants’ accounts of broken things, which undermines timely maintenance attendance and tenants’ ongoing willingness to report disrepair. ²¹

However, Murphy’s complaints were not simply ignored. Instead, the coronial report described systemic and individual failures to execute work orders generated in response to Murphy’s communications. Consistent with Demed’s subcontracting arrangement at Gunbalanya years later, T&J Contractors (T&J) were contracted by the NT government to deliver maintenance services at the Blain St complex and received maintenance orders from the department – at that time, the Department of Local Government, Housing and Sport. While T&J received an order regarding the immediate motor replacement at Murphy’s unit as early as 20 December 2004, this did not occur. The coroner described that

[a]n error by an electrician employed by T&J resulted in an entirely different unit [Flat 12] being examined and repaired on 20 December 2004 and the EAC in question not even being looked at. ²²

Instead, confusion about work orders led to an invoice being created for motor replacement at Flat 13, despite it not being attended to.

Tenant complaints signalling an ongoing problem continued in the months that followed. The coroner identified that T&J was ‘extremely slow’ to respond to maintenance orders throughout February 2005 and that T&J ‘had known that a new motor was required for 12 days before the death occurred but nonetheless an electrician was not sent out and the motor was not replaced.’ ²³ Rather than maintenance orders being interpreted as indicating the risks posed by housing disrepair, the non-response exemplifies a typical presumption that housing is safe by default, if not providing high amenity to residents. During this period, all EACs in Tennant Creek public housing were in fact subject to cyclical pre-season maintenance (including cleaning the pads, flushing the tank, and flushing the lines). But such maintenance did not include electrical safety checks and was usually undertaken by trades assistants rather than qualified electricians. As in Rory’s case, the coroner noted that Monica’s ‘was a preventable death’. ²⁴

Almost two decades later, there were also ample recorded warnings of the danger that caused the death of Kumanjayi Fly in April 2023 at Watiyawanu (Mt Liebig). ²⁵ Kumanjayi Fly, aged two, died after falling into a septic tank at his public housing home, when the ‘cover failed because of corrosion at the access point which meant it did not sit or seat properly.’ ²⁶ As in Monica Presley’s case, there was extensive documentation signalling the risks associated with the septic tank at Lot 8 in Watiyawanu. In 2019, following the commission of extensions to community houses, a plumber was contracted to assess whether septic systems would also require upgrading. The plumbing report recorded the access covers at Kumanjayi Fly’s home as being ‘incorrect’, that the tanks in the community were ‘generally in poor condition’, and that at Lot 8 the tanks were ‘non-compliant due to the fact that the access covers are incorrect, missing bollards/protection, no distribution pit, joint putty coming adrift from the saddle riser and tank, [and] baffles corroded’. ²⁷

In this case, maintenance records had documented problems with the septic system, but had not prompted the requisite action by the Department of Territory Families, Housing and Communities (‘the housing department’) and the Department of Infrastructure, Planning and Logistics (‘the infrastructure department’). From 2018 to 2022, at Lot 8, ‘the septic tanks or leach drains were pumped out 13 times’, declared ‘an extraordinary number’ by a wastewater expert. ²⁸ The leach drains were also extended or replaced in 2016, 2018, 2021 and 2022, while the relevant standards specify that a system should have a serviceable life of at least 15 years. ²⁹

The coroner stated that the plumbing report’s ‘safety concerns were neither addressed nor properly investigated prior to Kumanjayi’s death’ and that ‘no one [in the housing department] was able to satisfactorily explain why the 2019 plumbing report was not properly actioned’. ³⁰ Instead of remediating the issues identified by the report, the Coroner described that the infrastructure department ³¹ instead sought a dispensation from compliance with the Code of Practice for On-Site Wastewater Management from the NT Department of Health, in order that house extensions could proceed. ³²

Rather than the incompetence evident in the Presley inquest, Kumanjayi Fly’s inquest found attempts to avoid attending to the maintenance issue. In communications with the Department of Health, the housing and infrastructure departments fallaciously argued that the addition of bedrooms would have no impact on resident numbers and that the septic system was functioning under the current load. ³³ Although the Department of Health sought further information regarding the exemption application for house extensions at Watiyawanu, the housing department failed to supply information or to determine whether the dispensation had been granted. The Coroner summarised that this was not a deferral of upgrades; rather, the housing and infrastructure ‘departments sat on their respective hands and failed to address the issue … for years.’ ³⁴ Collectively, the coronial reports demonstrate that, while maintenance records are necessary to ensure safe and secure housing, the presence of documented information is insufficient to guarantee action by the responsible parties.

Preventive maintenance

Consistent in these coronial reports published across 18 years is the identification that a preventive maintenance regime for public housing would likely have avoided ‘preventable’ deaths. In relation to Kumanjayi Fly, the Coroner recommended that ‘[t]here must be a prioritised and timely progression to cyclical or planned maintenance for remote public housing septic systems’. ³⁵ This is consistent with best practice asset management in other Australian state and territory jurisdictions. For example, on the Aṉangu Pitjantjatjara Yankunytjatjara (APY) Lands in northwest South Australia, the South Australian Housing Trust manages a planned maintenance program that includes scheduled visits focused on electrical safety, plumbing, air conditioning, building fabric, septic systems, pest control and hot water systems. ³⁶

Also consistent across the coronial reports is the extensive auditing and remediation work undertaken in response to the deaths. Following Rory’s death at Gunbalanya, between 11 and 18 November 2020, PAWC inspected 279 overhead services in the community and ‘found 45 defects including three further services that had degraded insulation of the service conductors and another five with installation issues.’ ³⁷ Demed also found that the failure to earth roofs and riser poles was repeated throughout Gunbalanya housing. By April 2021, PAWC had inspected every service wire in the 72 remote communities for which it was responsible. It conceded that an inspection and maintenance program for all electrical infrastructure was required and estimated this would be operative across remote communities within two years. ³⁸

In response to Monica Presley’s death at Tennant Creek, electrical checks were done on all the EACs at the Blain St Complex, with numerous faults discovered. T&J made various interventions to the hardware design and job delivery processes to increase the safety of EACs and, by April 2006, 13 months after Monica Presley’s death:

certificates of compliance had been issued for [EACS at] all public housing in Tennant Creek and Elliot and for 85% of public housing in Alice Springs and Ti Tree, the other 15% [Territory Housing] had not yet been able to gain access to. ³⁹

Unlike some other Australian state and territory jurisdictions, ⁴⁰ the Coroners Act 1993 (NT) obliges relevant departments to respond to the coroner’s findings or recommendations in a report to the Attorney-General, tabled before the Legislative Assembly. The report prepared by the Chief Executive of the NT Department of Justice in response to the coroner’s recommendations in Monica Presley’s inquest described a planned maintenance approach to EACs and specified an asset maintenance model to be trialled at public housing in Tennant Creek. ⁴¹

Following Kumanjayi Fly’s death at Watiyawanu, contractors were engaged to make safe the septic tank at Lot 8, to audit septic tank access covers across Watiyawanu and rectify safety risks, and to replace all septic systems identified in the 2019 report. Further afield, a requirement to install a secondary barrier for compliant septic tanks was established, and an NT-wide ‘audit was commissioned to inspect access covers at septic tanks installed not just in public houses but also government employee housing’. ⁴² The Department of Infrastructure, Planning and Logistics also committed to establishing a rolling housing asset condition program, on behalf of identifying urgent work and a longer-term planned maintenance schedule.

Collectively, the inquest accounts from interested parties concerned with policy and programmatic responses to specific deaths effectively historicise the risks that contributed to the deaths. The inquests effect a discursive shoring up of confidence in the housing system, such that we should not expect similar incidents in the future. ⁴³ In this way, the inquests under consideration make a strong argument for preventive maintenance programs, to maintain house function and reduce risks to residents. This is a current NT policy priority, and for the first time specific funding was allocated to preventive maintenance in the recent remote housing funding agreement between the Commonwealth and NT governments. ⁴⁴ A revised maintenance program now includes funding for preventive maintenance works including NT-wide pest control, targeted septic tank maintenance, ad hoc subcontracting of the not-for-profit company Healthabitat to deliver community-specific ‘Housing for Health’ programs, and a pilot cyclical maintenance program at selected communities. ⁴⁵

However, it is notable that in response to the coroner’s recommendation in 2007 to shift from an emphasis on reactive repairs to planned maintenance, the general manager of Territory Housing ‘gave evidence that this [is] not something new in response to the accident, but had been part of the strategic priorities of Territory Housing since 2005.’ ⁴⁶ Similarly, the Commonwealth government’s review of the National Partnership Agreement for Remote Indigenous Housing (NPARIH, 2008–2018) recommended ‘an increased emphasis on planned cyclic maintenance’, ⁴⁷ which echoed a NPARIH goal established a decade earlier, to implement ‘robust and standardised property and tenancy management of all remote Indigenous housing’. ⁴⁸ This goal was also evident in the NT government’s more recent Healthy Homes remote housing maintenance program. ⁴⁹ Healthy Homes sought to prioritise a preventive maintenance approach but failed to mainstream condition assessment tool inspections, its main means for doing so. ⁵⁰

Throughout these reviews, policies and coronial reports, the refrain for preventive maintenance is more than ‘colony-maintenance’ ⁵¹ or the ‘remedial circularity’ ⁵² of a self-sustaining government bureaucracy, identifying shortcomings to justify further interventions in Indigenous lifeworlds. Such recommendations exemplify the death prevention ⁵³ or ‘prophylactic role of the Coroners Court’ ⁵⁴ and recognise that preventive maintenance is worth pursuing because housing is always ‘disassembling’. ⁵⁵ Nonetheless, while the goal to institute preventive maintenance has long been entrenched in State discourse, it has rarely been progressed beyond a policy promise except in response to a preventable death. The failure to establish a preventive maintenance program mainstreamed across remote community housing, despite consistent calls to do so, is akin to the failure of an individual maintenance officer to execute an urgent work order. Responsibility is diffused across time and parties, but the consequence is the same.

Housing harms

The three inquests considered above have obvious similarities. They each involve Aboriginal children living in public housing, for which the NT government was landlord. In each instance, the danger could have been mitigated by a preventive maintenance program, and in two cases (Monica Presley and Kumanjayi Fly) the dangers were well-known but inadequately addressed. Together, they highlight housing’s most direct and acute dangers and make a strong case for preventive maintenance to mitigate risk.

Drawing on the coronial archive, there are alternative starting points to examine housing harms. These alternative starting points are nonetheless consistent with the approach taken here, whereby housing is considered for the risks it poses, and as an object of policymaking, government intervention, and contestation over responsibilities that exacerbate those risks. In addition to the cases considered above, we might commence an examination of housing harms with any of the inquests investigating the deaths of:

• Albert Robbo, killed after being run over by police while sleeping rough; ⁵⁶ or

• Deborah Melville, who died of septicaemia and pyaemia after a minor sporting injury was untreated while living in ‘deplorable neglect’ in foster care; ⁵⁷ or

• Michael Aubrey Campbell, who died after suffering acute heat stress at or around his public housing home; ⁵⁸ or

• Sammy, who died by suicide in a foster care situation that did not follow the Aboriginal Placement Principle. ⁵⁹

And so on. The cases listed here are examples of deaths in which housing, and relevant government departments, are not typically implicated. However, in each instance the failure of the housing system played a significant role in contributing to a preventable death.

Housing haunts the coronial archive in myriad ways beyond its presence as a direct cause of death. ⁶⁰ In some accounts, housing is identified as a contributing factor to an event, such as sleeping rough at a Beaurepaires premises. ⁶¹ In other coronial reports, housing is granted little attention but is nevertheless central, such as in domestic violence-related deaths where the victim’s capacity to escape was severely circumscribed by the availability of alternative accommodation. ⁶² The ethnographic detail of coronial reports provides perspectives on how housing functions as a social determinant of death, with potential to progress analyses of housing harm beyond an environmental health framework and its narrow focus on resident ill-health and injury. Drawing on the inquisitorial approach and narrative representation of the coronial inquest allows us to better understand how State interventions in remote housing also exacerbate housing’s disassembly. With this view, we can more judiciously adjudicate the sorts of interventions that are most likely to increase the safety and wellbeing of householders, which include – but are not limited to – preventive maintenance.