Lessons learnt from tragedy - the importance of getting fire precautions right

The following article unfortunately shows an example of poor training of both staff and inspectors and bad practice the events chronicled could have happened anywhere throughout the UK and in any care-home or sleeping establishment. It shows the importance of using a company which is independently 3rd party audited to ensure that quality standards are established and maintained. Report from the Herald Scotland read the full article here.

The longest-running fatal accident inquiry in Scotland’s legal history finished yesterday with an emotional farewell to the families of those who lost their lives in the Rosepark Care Home fire.

Sheriff Principal Brian Lockhart drew a line under nine months of evidence into the tragedy, which killed 14 pensioners in January 2004, by offering his sympathies to the loved ones of those who died.

As he struggled to maintain his composure, Sheriff Principal Lockhart turned to the gallery where a dozen bereaved relatives have sat throughout the inquiry. He said: “It only remains for me to say that I offer my sincerest condolences to those of you who have lost relatives in this tragedy. One of the unfortunate aspects in inquiries such as this is that you never have the chance to get to know the people most interested in its outcome.”

More that 141 days of evidence were heard with 145 files of documentary evidence at the inquiry, which Sheriff Principal Lockhart described as “exceptional both in terms of its length and complexity”.

The inquiry has exposed a domino effect of weaknesses and oversights that contributed to the fire and its death toll at the home in Uddingston, Lanarkshire.

Sheriff Principal Lockhart will now unpick nine months of evidence to establish all the circumstances which led to the fire – widely believed to be started by an electrical fault – and to determine what must be done to ensure a fire like it never happens again. The key areas of interest are likely to be:

THE BUILDING

Rosepark was considered a modern, safe example of the new breed of private care homes that sprung up in the early 1990s.

But beneath the surface of the home lay a major safety risk that was not discovered until after the fire.

The inquiry heard that Mr Balmer never knowingly cut corners in the building and running of the home.

He hired Star Electrical, run by now-retired George Harvie, to fit the ventilation system at the home, after rejecting a more expensive quote from another firm.

But crucially, fire dampers were never fitted, allowing smoke to sweep and spread through the fabric of the building on the night of the fire.

Architect William Dickie included the installation of fire dampers but was hired by Mr Balmer on a plans-only basis and was not paid to carry out regular site inspections.

Mr Balmer chose to oversee the construction himself, and was responsible for ensuring the building was constructed according to plan.

It has also emerged that annual inspections of the home’s electrical installations did not meet the legal requirements.

Despite the hidden dangers at Rosepark, Mr Balmer told staff on several occasions he was quite confident that Rosepark was a very safe place to be.

FIRE SAFETY

The Balmers were informed a year before the tragedy that the risk to life was high at Rosepark because of a lack of regular fire drills.

Yet not all of the recommendations made by consultant James Reid, hired by the Balmers to provide fire safety guidance, were met by the time of the blaze in January 2004.

The owners were advised to carry out fire drills every six months, and one was held a month after his report was received. But records revealed a gap of 11 months before the next one was held – just weeks before the fatal blaze.

Mr Reid also emphasised the importance of carrying out night evacuations but the quality of his report was scrutinised at the inquiry with weaknesses found in several key areas. He admitted serious failings, including the omission of an evacuation plan. Staff were advised in their contracts that fire drills were mandatory but two former employees told the inquiry that they had no experience of the procedure.

Records did show that at least three drills were carried out between 2002 and 2004, but not all staff had been involved with them.

When Flora Ann Davidson, a staff nurse on regular night duty, was asked whether she had ever given thought to how residents would be evacuated, she told the inquiry: “You just hope it doesn’t happen.”

Matron Sarah Meany was ultimately in charge of fire policy at the home after being named in safety documents by Mr Balmer, but she was not fully briefed of her duties. She was never trained or had a budget to carry out fire drills.

POOR STAFF TRAINING

Staff delayed calling the fire service for nine to 10 minutes after the alarm sounded on the night of the blaze and it became clear during the inquiry that they were unsure about what to do in the event of fire. The purchase of a fire safety video in 1998, to be shown to existing staff and new recruits, seemed only to add to the confusion.

The video made clear that staff should dial 999 if the fire alarm went off, but should go and investigate the building first to rule out a false alarm. Mr Balmer did not take on board the guidance in the fire safety training video because he thought it was too generic.

On the night of the fire, staff were milling around, unsure of procedures, as flames spread. Two nurses did go and check the building and found thick, acrid smoke in the corridor closest to a linen cupboard, the seat of the fire.

The fire alarm panel was changed just days before the fire, with staff not shown how to use it. Footage showed attempts to turn the fire alarm off.

INSPECTIONS

The Care Commission took responsibility for inspecting care homes in 2002 from local health boards, but was not specifically trained in assessing fire safety standards in place.

The inquiry heard that inspec tors from Scotland’s care sector watchdog failed to pick up on safety breaches and the lack of fire drills at Rosepark in 2003, less than a year before the blaze.

Care Commission inspectors checked only that procedures were in place to meet fire regulations, such as fire drills and staff training, but no assessment was made whether that procedure was adequate or not.

Fire officers also took no enforcement role in fire safety matters at care homes, with no inspection carried out in the 12 years between the opening of Rosepark and the fatal fire.

Fire brigade staff did visit the home to give fire safety lectures, but it was down to employees to point out if any of the advice given was not being followed.

BEDROOMS

The bedrooms at Rosepark were a recurring area of interest at the inquiry. Many of the residents died in their beds, their rooms turned into furnaces with temperatures reaching an estimated 540ºC.

This was largely because residents were allowed to sleep with their doors open, which allowed the fire to spread quickly and was in breach of fire safety regulations.

Each bedroom door should have been fitted with an automatic door closure so that it could easily swing back to its frame.

But a number of residents wanted their door propped open at night. Some did not like being cut off from the care of the nurses, others had health problems that made them fearful of the dark.

One fire scientist told the inquiry that residents could have been kept safe for a full two hours if their doors had been closed and a sprinkler system was in place to keep the fire under control.

The expert estimated that the survival time for residents who kept their doors open at night would be less than eight minutes.

EMERGENCY CALL-OUT

Strathclyde Fire and Rescue’s initial response to the blaze came under heavy questioning.

It took seven minutes from the time of the arrival of crews at Rosepark to send in the first firefighters in breathing apparatus.

This was partly due to engines pulling up at the wrong entrance to the home and being met with a pair of locked gates.

A computer with access to fire safety information about the premises, including the number of residents and the location of fire hydrants, was not working on the night of the fire.

Following an initial check of the premises, Steven Campbell, a former senior fire officer at Bellshill, was satisfied that the fire was contained in a lift shaft.

He did not call for back-up at the time as he believed it would have been a knee-jerk reaction. But Mr Campbell was unaware that smoke was circulating in the corridor behind the lift shaft, where residents lay trapped by the fire.

His firefighters did what they could. They raced from room to room, looking for trapped pensioners, ignoring safety protocols in a bid to reach the victims as quickly as they could. But 10 residents did not make it out alive that night.

A further four later died in hospital, all killed by the thick black smoke which had filled the rooms where they slept.

How care home family twice avoided prosecution

THE OWNERS

TWO unsuccessful attempts have been made to prosecute the Balmers over the deaths of 14 pensioners at their care home.

Thomas and Anne Balmer, and their son Alan, of Bothwell, saw 12 charges against them dropped in 2007 because of the way the allegations over health and safety breaches were worded by the Crown Office. The High Court in Glasgow was told that the Balmers could not be held criminally liable because they had dissolved the firm which owned Rosepark Care Home and set up a limited company – 13 months after the fire, but before the indictment was served.

Lord Hardie said the Balmers could be charged again and also granted the Crown Office the right to appeal against his decision. However, the Appeal Court ruled, in July 2008, that the Crown could not proceed with the indictment as the firm had been dissolved.

In May 2009, the Balmers again avoided prosecution when 17 charges against them were dismissed. Lord Matthews said it was “fatal” that the Balmers had been indicted as the surviving partners of the now dissolved firm of Rosepark Care Home, in Uddingston, Lanarkshire.

He said: “The surviving partners are not in law liable for the criminal acts of the firm, assuming there were any.”

The Crown Office said yesterday that a change in law at Westminster level was still required before any further attempts at prosecution could be considered.

We came here to see justice done at last

THE RELATIVES

ROBERT MacLachlan and his partner Brian Patton have travelled from their home in Berwickshire to Motherwell for almost every day of evidence since the inquiry into the Rosepark blaze began in November last year.

They are among around a dozen bereaved relatives who have gathered day after day in the gallery of the makeshift courtroom in the Gospel Literature Outreach Centre, listening to details on everything from how the home’s washing machines were wired to the legal minutiae of regulation and inspection, and even viewing harrowing CCTV footage from the night of the blaze and video reconstructions of it by fire scientists.

Mr MacLachlan, a retired doctor whose 93-year-old mother, Isabella, had been a resident at Rosepark for almost two years at the time of the fire in 2004, said he came to see justice done at last.

He said: “We were so annoyed that the criminal prosecutions fell through despite several attempts, not through any fault of the Crown but because of a loophole in the law. It was very much a response to that.”

He was left with a sense of Rosepark much at odds with his first impression of its homely and modern surroundings.

“What surprised us was what was under the surface: the lack of dampers, the failures in staff training and the confusion over phoning the fire brigade which meant that nine, 10 minutes were lost.

“The discrepancy between what we saw and what we got. If there had been a criminal prosecution we would never have found out as much as we’ve learned here.”