Abstract: At approximately 11:00 a.m. on February 15, 1991, Employee #1, a pastoral associate of Wesley United Methodist Church, was setting up for a retreat that was to be held the next day at Coburg United Methodist Church. She had finished vacuuming the social hall when she entered a hallway in which there are three identical doors on the right. The first leads to a basement, the second to a men's room (as marked) and the third to a women's room. Not being familiar with the church, the employee apparently mistook the basement door for that of the women's room. The basement door, which until recently had two locks, swings outward and the stairway light is normally left off. There is an immediate 8 in. drop from the threshold to the first step and then nine risers in a stairway leading to a cement basement floor. Employee #1 was seen to fall backward down the stairs, landing on her back and suffering a skull fracture. She was transported to Sacred Heart Hospital, where she died on February 18, 1991.