Case Commentary

Death Inquest — Coroner returns verdict of death by misadventure for firefighters killed during firefighting operations at mini-storage facility

 The Coroner made 14 recommendations to various Government departments and properly interested persons, including the adoption of a licensing system to regulate mini-storage facilities to ensure compliance with fire safety rules.

Re Hui Chi-kit 許志傑, deceased

Reference: CCDI-334/2016
Court:        Coroner’s Court
Before: Coroner Mr. Philip Wong Wai-kuen
Appearance: Jeffrey Tam acted for the family of Senior Fireman Hui Chi-kit at the inquest, and with Angela Mui during the pre-inquest review, instructed by Alex To & Co. Solicitors
Date of Decision:   11 May 2022


Concluding one of the longest death inquests ever held in Hong Kong, Coroner Mr. Philip Wong Wai-kuen ruled that the two firefighters who lost their lives while battling the fourth-alarm blaze at Amoycan Industrial Centre in 2016 had died of misadventure.

The Coroner accepted the submissions made by Jeffrey Tam, who represented the family of the late Senior Fireman Hui Chi-kit, on various points including the failure of the mini storage facility’s staff to report the fire to the police promptly, and the failure on the part of high-ranking officers at the Fire Services Department to keep frontline firefighters adequately informed on the scene of the fire and other important details.

The Coroner made 14 recommendations to various Government departments and properly interested persons, including the adoption of a licensing system to regulate mini-storage facilities to ensure compliance with fire safety rules.


Station Officer Thomas Cheung and Senior Fireman Hui Chi-kit (“Hui”) were firefighters who died in the midst of carrying out their duties during the fourth-alarm fire at the Amoycan Industrial Centre in Ngau Tau Kok. The blaze, which broke out at a mini-storage facility of SC Storage, burned for 108 hours and 16 minutes from 21 June to 25 June 2016, making it the longest-running fire at an industrial premises in Hong Kong history and the seventh-longest of any fire in Hong Kong. 

Hui joined the Fire Services Department in 1998 and was promoted to Senior Fireman in June 2016. On the third day of firefighting operations at Amoycan Industrial Centre, Hui was found collapsed inside a cubicle at the mini-storage facility, and later certified dead at the hospital.

Prior to his death, Hui did not suffer from any serious or long-term illness. He achieved A grade for every annual physical fitness test he took since graduating from the Fire Services Training School.

Testimonies of key witnesses

Staff from SC Storage and Hang Lung Properties

The evidence given by the staff from SC Storage and its landlord, Hang Lung Properties, revealed that it took them around 30 minutes to make a police report after discovering the fire. According to the simulation prepared by Professor Yuen Wai-keung on the outbreak and spread of fire, a secondary fire could have spread within the first 30 minutes of its initial outbreak.

According to the staff, they had not received any basic training for responding to a fire breakout, nor were they familiar with using the fire extinguisher and fire alarm bell.

As for the mini-storage facility, the evidence revealed that its design did not comply with the Buildings Ordinance (Cap. 123). Nor was there any system to effectively enforce the provisions in the tenancy agreement, including the prohibition against storage of dangerous goods in the cubicles.

Fire Services Department Officers

Probationary Station Officer Yau Hui-sang, Fireman Yuen Yiu-keung and Fireman Chui Kin-man all worked with Hui in the same crew (“the Firefighting Crew“).

Giving evidence at the inquest, they confirmed that they were not given the flor plan nor told about the spots with weak or no radio signal before entering the scene of the fire. As they broke open the mini-storage cubicles, the pressure of the hose suddenly dropped and the jet became weak for around 10 seconds. The Firefighting Crew did not communicate this to their Entry Control Officer and continued with their duties. 

At one point, Hui’s air cylinder content was at 110 bar, the lowest level among the Firefighting Crew. When Probationary Station Officer Yau Hui-sang tried to contact the Entry Control Officer for the arrangement of relief, no response was received; this was also the experience of the other firefighter witnesses who entered the scene of the fire before the Firefighting Crew did. Similarly, when the Entry Control Officer attempted to inform the Firefighting Crew that they had 10 minutes work time left, no response came. 

Subsequently, Probationary Station Officer Yau parted ways with the rest of the Firefighting Crew. The remaining firefighters including Hui struggled to remove a metal panel off a mini-storage cubicle, but to no avail.

Hui was later found unconscious and collapsed against the metal panel by Senior Officer Wan Chi-ping. Hui was still breathing faintly. Another group of firefighters were summoned to relieve Hui and his colleagues; at the time, they did not perform any checks on Hui’s condition and his breathing apparatus. 

Hospital Doctors

The Accident & Emergency doctor suspected that Hui’s actual body temperature was higher than the recorded 40.6 degree Celsius, which was far above the temperature which corresponds to a heat stroke. Heat strokes occur under high-temperature environment in which the body’s mechanism cannot cool down through sweating, thus causing damage to the body. 

Dr. Victor Sim Man-fai, expert witness for SC Storage, told the Court that Hui’s direct cause of death was fatal arrhythmia likely prompted by the 75% occlusion of the major coronary arteries — a pre-existing condition of Hui’s.

According to pathology specialist Dr. Joey Lam Wai-man, Hui could have suffered from heart failure due to heat stroke, regardless of whether he had the pre-existing condition. In the absence of any suggestions that scabs or scars that signalled exacerbated occlusion were found on Hui’s heart, Doctor Lam concluded that Hui’s cause of death was heat stroke. 

Coroner’s Verdict and Recommendations

At the end of the 65-day death inquest which spanned eight months, the Coroner found that Hui died from heat stroke and ruled that the cause of death was misadventure.

In addition, the Coroner accepted various submissions made by Jeffrey Tam, who represented Hui’s family, about the failures of ministorage staff to report to the police promptly, inadequate training of mini-storage staff to combat fire hazard and insufficient safeguard to ensure mini-storage tenants not to store inflammable explosives. 

As to the Fire Services Department, the Coroner also accepts Jeffrey’s submissions that there were failures on the part of high-ranking officers to provide frontline firefighters with adequate information (about the scene of the fire, the tasks performed by the previous crew, and anything else that warranted caution) and to adhere to Mayday procedure, and the Department lacked a systematic way to disseminate information to firefighters on the next shift. 

On this basis, the Coroner made four recommendations to the Fire Services Department:

• Pay close attention to and conduct assessments for firefighters above 30 years old to check for the potential risk of suffering from cardiovascular disease. and provide relevant medical examinations if necessary.

• Require all frontline commanding officers to regularly attend courses on managing fires of No. 3 Alarm magnitude or above.

• Mandate all tenants of industrial buildings to send representatives to attend fire drills.

• Conduct a comprehensive review of its mechanism for disseminating information.

As regards the Buildings Department, the Coroner recommended it to actively consider adopting a licensing system to regulate the operation of mini-storage facilities.

In relation to the Labour Department, the Coroner made the following two recommendations:

• Mandate all managerial staff of mini-storage facility operators to complete courses on fire prevention.

• Strengthen the inspection of fire facilities and the relevant records and equipment for escape routes.

The Coroner made six recommendations to the mini-storage operator SC Storage:

• Undertake to improve employees’ awareness of how to safeguard lives and properties in case of fire.

• Ensure, where practicable, that its customers/tenants would not store hazardous items.

• Require all employees to regularly attend fire drills and courses on fire prevention.

• Update the floor plan of mini-storage facilities in a timely and accurate manner.

• Store the records of customers/tenants entering and leaving the mini-storage warehouse on cloud service.

• Immediately check if fire escape facilities need repair, and carry out any repairs required.

Further, the Coroner recommended Hang Lung Properties to strengthen the fire prevention and response knowledge of staff outsourced from its security provider. 

Media Coverage:

The inquest has been widely reported in local media, including: 

• (English) SCMP, The Standard

• (Chinese) Ming Pao News, HK01, The Headline



Jeffrey Tam

“Jeffrey Tam of Denis Chang’s Chambers stands out in the opinion of several interviewees as a barrister who is ‘very sound and reliable in the public law area’ generally and … he also operates a broad commercial practice, embracing, among other matters, shareholder and securities-related issues.”
Chambers & Partners Greater China Region 2022 — Commercial Dispute Resolution: The Bar (Spotlight Table)

“Jeffrey is a very reliable junior. He has good analytical abilities and is very knowledgeable in public law matters.”
Legal500 (Legalese) 2022 – Administrative and Public Law: Leading Junior

Jeffrey also specialises in representing properly interested persons in death inquests. He acted for the HKPTU in the inquest into the suicide of a primary school teacher and, in another inquest, represented the school in the inquiry into a student’s death during physical education class

Find out more from Jeffrey’s profile.

Angela Mui


Angela’s civil practice encompasses matters such as defamation, commercial, probate, family trust, personal injuries, land and conveyancing, securities and finance, employment disputes, professional disciplinary actions and judicial review.

In the area of defamation, she has advised authors of the publisher, Penguin Books, on potential issues of defamation; she has also appeared before the Court of Appeal and the Court of Final Appeal in Chang Wa Shan v Esther Chan Pui Kwan (2018) 21 HKCFAR 370, which is also reported in the UK Entertainment and Media Law Reports [2019] EMLR 10. Together with Jeffrey Tam, she acted for the HKPTU in the inquest into the suicide of a primary school teacher and, in another inquest, represented the school in the inquiry into a student’s death during physical education class

Visit Angela’s profile for more details.


This article was first published on 11 May 2022.

Disclaimer: This article does not constitute legal advice and seeks to set out the general principles of the law. Detailed advice should therefore be sought from a legal professional relating to the individual merits and facts of a particular case. The photograph which appears in this article is included for decorative purposes only and should not be taken as a depiction of any matter to which the case is related.